unu-cbg new casemix system tool

8/10/2019 UNU-CBG New Casemix System Tool

1/19

4/5/11

1

UNU-CBG: New Casemix System Tool ToEnhance Quality and Efficiency in Developing

Countries

International Institute For GlobalHealth (UNU-IIGH)

Professor Dr Syed Mohamed Aljunid

MD (UKM) MSc (Public Health)( Singapore) PhD (London); DLSHTM(London); FAMM

Professor of Health Economics & Consultant Public HealthMedicine

Senior Research Fellow

United Nations University-International Institute ForGlobal Health

Kuala Lumpur

a enges n oc a eaInsurance Schemes in Developing

Countries! Low coverage (breath and depth)

! Inadequate resources especially for social insurance

! Unaffordable Premium especially for poor and near poor

! Limited Benefit package

! High level of inefficiency

! High administrative cost! Moral Hazards of Consumers and Providers

! Delay in claim processing

! Poor Provider Payment Mechanisms! Use of retrospective payment methods (e.g. FFS/Itemised bill)

! Services Of Poor Quality! Lack of proper review and monitoring

! Low patient satisfaction


2/19

4/5/11

2

! Reduce Administrative Cost! Should not be more than 10% of operating cost

! Control of moral hazards

Effective and efficient ways of controlling moral hazards

! Consumers: Co-payment

!

Providers: Utilisation Review, Medical Audit

!

Use efficient provider payment mechanism

! Regular Review of Benefit Package!

Include new services

! Exclude non-essential services

! Work with the Stakeholders

! Increase acceptance of consumers & providers

Whatis Casemix System ?

Casemix System is a classification

ofpatient treatment episodes

designed to create classes which

are relatively homogenousinrespect of the resources usedand

which contain patients with

similar clinical characteristics.

(George Palmer, Beth Reid,2000)


3/19

4/5/11

3

What is Casemix?

" Refers to the Type and Range of Cases

treated in hospitals and clinics

"

Defines Hospital Final Output, Classified intoPredetermined Categories

" Provides Information on Resource Use andQuality

" Describes patients characteristics including

outcome of care

" Can be used as standards for comparison

Benefits of Using CasemixSystem

!

Improve Efficiency of Health Care Services health

"Identify unnecessary services

"Reduce wastages and Cost Savings

!

Improve Quality of Care

"Enhance Quality Assurance Programme

"Facilitate Benchmarking Exercise

"Improve Patient Satisfaction

! Improve Health Management Information System

"Provide high quality data on patient care

"Provide information for review and monitoring

"Promote Better Decision Making

"Encourage Evidence-Based Practice


4/19

4/5/11

4

Case-mix System Reimbursement:Advantages

!

Risk shared between funders and providers

!

Remove incentive to over treat patients#Payment based on package

! Fair remuneration to providers

#Payment based on severity level

! Payment based on productivity

#Payment based on intensity of care not just volumes

!

Enhance Quality Assurance Programme

! Transparency and objective in computation of tariff

Case-mix SystemReimbursement: Advantages

! Faster and easier to Process Payment

! Easier to verify claims

! Tariff can be easily updated

!Annual updating of Hospital Base-Rates

!Annual/Bi-Annual updating of Cost-weights

! Fraudulence Claims can be detected

and avoided

!Assignment of severity level by grouper

! Random checking can be easily done


5/19


6/19

4/5/11

6

Casemix System in Developing Countries:The Obstacles

! Limited Access to Casemix Tool Casemix Groupers are mainly proprietary owned

Difficult to be customised for local need

Need access to source code for customisation

! Lack of Financial Resources! Case-Mix Consultants are expensive

! Commercial Case-Mix Softwares are costly

! Slow acceptance by Practitioners

! No capacity to refine or expand case-Mix groupings

! No groupings for chronic diseases/subacute cases

! Tariff not updated

! No continuous refinement of DRGs groupings not refined

What Do We Do inUNU-IIGH?......

! Build human resource capacity inCasemix

! Series of Training Workshops

!

E-learning Programme! Support local development of casemix system

! Provide access to Casemix Tool! Casemix Grouper

! Digital Coding Tool

! Clinical Costing Software


7/19

4/5/11

7

Implementation of Case-Mix System inDeveloping Countries

Disease &

Procedure Codes

Financial

Data

CCM

DRG-

Grouper

Cost-Weights

CUSTOMISED

DRG

GROUPER

Hospital Base

Rate

NATIONAL

HOSPITAL

TARIFF

Case-Mix Index

Softwares in Case-Mix System

! Digital Coding Tool

! Data Tool- Assist to enhance productivity of Coders

! UNU-Code Assist- Assist in Verifications of Casemix codingand grouping

! Case-Mix Grouper

! UNU-CMG Grouper

! Costing Tool! CCM Version 2.0-UKM/UNU

! Costing Template for Hospital Base-Rates

! Costing Template for National Tariff


8/19


9/19

4/5/11

9

Weaknesses of Current Case-mix Groupers ..

! Not designed to group sub-acute and chroniccases

! Sub-acute cases

!Very complicated Cases

! Moderately long stay cases

! Chronic cases

! Mental illness

! Long term rehabilitation

! Social welfare cases

!Very long stay cases

Weaknesses of Current Case-mix Groupers

! Produced unhomogenous DRG groups

! Tariff developed unsuitable for payment of

! Chronic Cases

! Cases with Prostheses

! E.g Hip Replacement. Below Knee Amputation

! Cases with special investigations

! E.g MRI/CT Scan

! Cases with special medications

! Chemotherapy

! Groupers do not have local costweights

! International Cost-weight international does not reflectactual cost locally

! Tariff using uncustomised costweights are unstable


10/19

4/5/11

10

Weaknesses of Current Case-mix Groupers

! Logic of grouper difficult to be modfied whencoding rules changed! Diagnosis ICD-11 from 2013 (Additional 7,800 codes Dx)

! Procedure ICHI from 2012 (WHO Procedural Classification)

! Severity level cannot be modified! Severity level remains the same

! Depend on the private companies

! Source code held by vendor

UNU-CBG:The New Casemix Grouper

! Grouper developed by researchers from United NationsUniversity

! UNU-International Institute For Global Health (Kuala Lumpur)

! UNU-International Institute For Software Technology (Macau)

! Research and Collaboration

! ITCC- International Training Centre on Case-Mix and Clinical Coding

! MOH of Developing Countries

! Asia Pacific Network of FIC

! WHO-FIC (ICD-10 and Procedure Classifications)

! Owned and Maintained by United Nations University

! United Nations University! United Nations Agency

! Non-for Profit and No Commercial Interest

!

Priority to support developing countries to achieve MDGs


11/19

4/5/11

11

What is UNU-Case-Mix Grouper?

!

Universal Grouper

! Cover all types of patients care

! Acute (In-patient/Outpatient)

! Sub-Acute (Moderately complex cases)

! Chronic Case (Long Stay Cases)

!

Dynamic Grouper

!

Total number of CBGs can be set-according to need of the country

! Severity level is not static

! Depending on types of patient care

! I to III

! I to IV

! I to IX

! I to X

! Very refined classifications

!

Advance Grouper

! Can be used with future changes in diagnosis and procedure classifications (ICD-11and ICHI classifications

EIGHT COMPONENTS OF UNU-CASEMIXGROUPER

UNU-GROUPER

ACUTE

SUB-ACUTE

CHRONIC

SPECIALPROCEDURES

SPECIALPROSTHESES

SPECIALDRUGS

SPECIALINVESTIGATIONS

AmbulatoryPackage


12/19

4/5/11

12

CASE-MIX MAIN GROUPS(CMGs)

! CMGs are the first level of classifications

! Labels in Alphabet (A to Z)

! Mostly equivalent to Chapters in ICD-10

! Correspond to Body Systems and Payment Package

! 31 CMGs in UNU Grouper

! 22 Acute Care CMGs

! 2 Ambulatory CMGs

! 2 Subacute and Chronic CMGs

! 4 Special CMGs

! 1 Error CMGs

! Total DRGs (CBGs)= 1,220 (Range: 314-1,250)

Case-Based Groups (CBGs)

! Second level of classification

! Organised in 5 alpha-numeric code! One letter and 4 numbers

! First Digit refers to CMG (Casemix Main Groups)

! Second Digit refer to Case-Type

! Third and Fourth Digit refer to specific DRG called

CBG

! Fifth Digit refer to severity level and resourceintensity level for specific package

! Consists of Medical/Surgical/Package Groups


13/19

4/5/11

13

UNU-IIGH Case-Mix Grouper-SERVICES COVERED

! Hospital In-patient

! Day Care Surgery

! Specialist Clinic

! Emergency Room

! General Out-patient

! Rehabilitation

! Chemotheraphy and

Radiotherapy

! Mental Health Servicesand Procedures

! Chronic cases

! Long Stayingpatients

! Specific PackageGroups$ Package Out Patient

$ Prostheses

$ Drugs

$ Procedures

$ Investigations

UNU-IIGH CAPACITY BUILDINGPROGRAMME ON CASE-MIX

SYSTEM


14/19

4/5/11

14

UNU-IIGH CAPACITY BUILDINGPROGRAMME ON CASE-MIX: The Benefits

! Softwares!

Digital Coding Tool-Data Tool Version 2.0

! UNU Case-mix CBG Grouper

! UNU-Code Assist Advance Coding Tool for Verifications

! Clinical Costing Software- Version 2.1

! Costing Template Software for Development of Hospital Base-Rates

! Costing Template Software for Development of National Tariff

! Access to DRG Logic of UNU Case-Mix Grouper!

MOH will have access to the UNU DRG Logic for futuredevelopment

! Training of MOH staff to use UNU DRG Logic for refinement ofcasemix groupings

! Joint Development of Future Case-Mix Grouper

List of UNU-IIGH TrainingWorkshops ( Three Days)

! Workshop 1

! Introduction to Case-MixSystem

! Workshop 2

! Coding of Diagnosis andProcedures for Case-Mix

! Workshop 3

! Installation and Maintenance of

UNU-IIGH Case-mix Software

! Workshop 4

! Case-mix Costing

! Workshop 5

! Clinical Pathways in Case-Mix

! Workshop 6

! Case-Mix Data Analysis

! Workshop 7

! Case-mix Costing Analysis

! Workshop 8

!

Customisation of UNU-IIGH Case-mix Software

! Workshop 9

! Development of Case-mix TariffFor Provider Payment

! Workshop 10

! Presentation of Final Results andNational Roll-out


15/19


16/19


17/19

4/5/11

17

UNU-IIGH Case-Mix Grouper


18/19

4/5/11

18

Clinical Costing Software

Countries working with UNU-IIGH on Casemix

!Asia! Indonesia

! Philippines

! Mongolia

! Vietnam! Malaysia

! Middle East

! Yemen

! United Arab Emirates

! Saudi Arabia

! South America

! Uruguay

! Chile


19/19

4/5/11

19

Conclusion

! Casemix system is an important tool to ensure sustainability ofsocial health financing programme

! Lack of capacity and inaccessibility to low cost but reliablegroupers are two major obstacles in case-mix implementation

! Most commercial groupers are costly and cannot be customised tomeet needs of developing countries

! UNU-CBG Case-mix Grouper: Universal, Dynamic and Advance

Grouper specially developed to support implementation of case-mixsystem in developing countries

! UNU-IIGH offer a complete package (capacity development/softwares) to facilitate implementation of case-mix system for indeveloping countries

unu-cbg new casemix system tool

Documents