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Casemix and information systems
Abstract
Casemix refers to a mix of patients classified in some way. It describes a system which groups patients by predetermined factors into clinically meaningful and resource homogenous groups to describe the hospital or health service product (a measure of output). A number of patient classification (casemix) systems have been developed for various purposes. The casemix system used by Australian acute care hospitals to define their 'products' is the Australian National Diagnosis Related Groups (AN-DRGS). Similarly patients may be grouped to represent homogeneity in terms of nursing resource usage. Such classification systems are therefore 'nursing casemix systems' and are used to describe the nursing department's products which are components of the hospital products. Other departments may also use a system to classify their patient services on the basis of resource usage in order to identify other product component costs. With a definition of the health service product it is possible to relate all inputs and processes to these products to support decision making at all levels within an organisation. This is highly desirable in a climate where accountability, efficiency and effectiveness are valued. Inputs consists of buildings, labour resources and supplies as well as the health status of individuals seeking health services. Processes consists of all that happens to and on behalf of the recipients of health care. Relating inputs to processes, outputs and outcomes for the purpose of performance evaluation requires effective and timely integrated information systems. Thus clinical and costing data need to be captured relative to intermediary and final products however defined. Information systems associated with casemix may be described as grouper software, costing systems, morbidity systems, hospital information systems, departmental (feeder) systems, including nursing workload monitoring systems, pathology, organ imaging systems and executive information systems. In fact most if not all health information systems may be related to casemix in some way.
... Casemix de ines a system in which patients are classi ied through a system that groups the patients by using a predetermined factor. The patients are grouped into more expressive and resource-identical groups to de ine the hospital health service product (Hovenga, 1996;Turner-Stokes et al., 2012). The casemix system can provide a clear picture of the treatment cost for different groups and individual patients. ...
... It has also become a universal measurement tool to analyze differences in clinical practices (Aisbett et al., 2007). All casemix systems use DRG to group the patients and de ine their products related to health services (Hovenga, 1996;Matsuda, 2007). DRG classi ication system was developed in 1960 by the Yale cater of Health studies to manage inpatient resources (Averill et al., 1998). ...
The current study was performed to develop a Diagnosis Related Group
(DRG) based casemix classification for inpatients. We applied a cross-sectional
retrospective approach to categorize the inpatients based on their
diagnosis and procedures at King Fahd Central Hospital (KFCH) Jazan, Saudi
Arabia. Inpatient discharge data from 2018 was considered, and patients
were categorized based on the casemix system. During the study period,
12,979 patients were discharged from the hospital. Of these, 38% of
cases were related to surgical procedures, and 62% were treated under
different medical specialties. The maximum number of procedures (19.8%)
performed were under the Case-Mix Group (CMG) "O" (deliveries). The
highest number (22.2%) of inpatient medical cases were observed in CMG
"B" (pancreatic system). 269 DRGs from different severity levels were
assigned to patient cases, and among these maximum number of patients
(12.1%) were found under DRG "Other liver diseases-mild." We developed
the DRG casemix system and categorized the patients according to their
Casemix and services provided during their stay at the hospital. Patient
identification and grouping based on the diagnosis and procedure is an
essential part of resource estimation process and can bring transparency
to the clinical practice. This study can potentially help public hospitals to
implement a DRG system for patient classification.
... DRG is a patient care classification system that was introduced in 1983 for the inpatient prospective payment system, an addition to the Medicare system in the United States [15]. It is a health management tool that categorises patients according to their similarities in clinical information and the healthcare resources used [15][16][17][18]. ...
... Service weights are related to DRG and describe the costs according to it for a particular service [19]. It is defined as the mean cost of specific services for any patient type, relative to the mean cost of all patient types [17]. Service weights are used to measure common resources consumed by patients in each DRG [5]. ...
Background
The current healthcare sector consists of diverse services to accommodate the high demands and expectations of the users. Nursing plays a major role in catering to these demands and expectations, but nursing costs and service weights are underestimated. Therefore, this study aimed to estimate the nursing costs and service weights as well as identify the factors that influence these costs.
Methods
A retrospective cross-sectional descriptive study was conducted at Universiti Kebangsaan Malaysia Medical Centre (UKMMC) using 85,042 hospital discharges from 2009 to 2012. A casemix costing method using the step-down approach was used to derive the nursing costs and service weights. The cost analysis was performed using the hospital data obtained from five departments of the UKMMC: Finance, Human Resource, Nursing Management, Maintenance and Medical Information. The costing data were trimmed using a low trim point and high trim point (L3H3) method.
Results
The highest nursing cost and service weights for medical cases were from F-4-13-II (bipolar disorders including mania - moderate, RM6,129; 4.9871). The highest nursing cost and service weights for surgical cases were from G-1-11-III (ventricular shunt - major, RM9,694; 7.8880). In obstetrics and gynaecology (O&G), the highest nursing cost and service weights were from O-6-10-III (caesarean section - major, RM2,515; 2.0467). Finally, the highest nursing cost and service weights for paediatric were from P-8-08-II (neonate birthweight > 2499 g with respiratory distress syndrome congenital pneumonia - moderate, RM1,300; 1.0582). Multiple linear regression analysis showed that nursing hours were significantly related to the following factors: length of stay (β = 7.6, p < 0.05), adult (β = − 6.0, p < 0.05), severity level I (β = − 3.2, p < 0.05), severity level III (β = 7.3, p < 0.05), male gender (β = − 4.2, p < 0.05), and the elderly (β = − 0.5, p < 0.05).
Conclusions
The results showed that nursing cost and service weights were higher in surgical cases compared to other disciplines such as medical, O&G and paediatric. This is possible as there are significant differences in the nursing activities and work processes between wards and specialities.
... • RQ 3. Which theories are frequently used together? (Co To address these questions, we analyze the usage of theory in papers published in Information Systems Research (ISR) in the period 1998 focus on these two journals ( Dennis et al. 2006). We use patterns of interaction in complex networks. ...
... , we analyze the usage of theory in papers published in MIS Quarterly the period 1998-2006, consistent with studies of researcher productivity that focus on these two journals ( Dennis et al. 2006). We use Complex Network Analysis for its ability A complex network refers to a wide variety of systems in nature and society, such as the World Wide Web (Adamic and Huberman 2000), film actor collaboration network ( Watts and Strogatz 1998), neural network of worms ( Barabasi and Albert 1999), and so on. ...
Effective application of theory is critical to the development of new knowledge in information systems (IS) research. However, theory foundations of IS research are understudied. Using Complex Network Analysis, we analyze theory usage in IS research published in two premier journals (MIS Quarterly and Information Systems Research) from 1998 to 2006. Four principal findings emerge from our analysis. First, in contrast with prior studies which found a lack of dominant theories at an aggregate level, we find stronger dominance of theory usage within individual streams of IS research. Second, IS research draws from a diverse set of disciplines, with Psychology emerging as a consistently dominant source of theories for IS during our study period. Moreover, theories originating in IS were found to be widely used in two streams of research (“IS development” and “IT and Individuals” streams) and more sparingly used in other streams. Third, IS research tends to form clusters of theory usage, with little crossover across clusters. Moreover, streams of IS research constitute distinct clusters of theory usage. Finally, theories originating from Economics, Strategy, and Organization Science tend to be used together, whereas those originating from Psychology, Sociology, and IS tend to be used together. Taken together, our results contribute to a scholarly understanding of theory foundations of IS research and illustrate methodological innovations in the study of theory use by employing Complex Network Analysis.
... 9 All case-mix systems used Diagnosis-related groups to define their products related to health services. 10 Accurate DRG-based cost information enables policymakers to detect resource consumption and sources for different treatment options more efficiently. ...
Health care systems aim to deliver high-quality medical care while considering efficient resource usage and cost-effective forms of interventions. Such purposes require scientific tools or mechanisms which aid in cost assessment before the efforts of cost reduction are considered. Diagnosis-related groups based costing methodology (Case-mix) is considered one of the preferred costing approaches in the health care sector. King Fahd Central hospital Jazan, the only tertiary hospital in the Jazan region, was selected for case-mix system-based patient-level costing of health services. The study’s objective was to estimate the cost per Diagnosis-Related Group (DRG) per inpatient admission and compare it with the already established average cost of health care services for inpatients. We applied a cross-sectional retrospective approach to categorize the inpatients based on their diagnosis and procedures and then estimate the actual cost of health care services provided to inpatients during 2018 and compared it with the average cost of the health services. There was a considerable difference between DRG-based costing (SAR 269,663,897) and average costing (SAR 247,035,938). The Diagnosis Related Group costing was found to be more reliable and representative of the services provided to the patients and is recommended to be used for reimbursement purposes.
... H ταξινόμηση κατά ομοειδείς διαγνωστικές ομάδες, αναπτύχθηκε στη δεκαετία του 70 από την ομάδα του Fetter (1985) στο Πανεπιστήμιο του Yale ως μία προσπάθεια να διακρίνει και να προσδιορίσει διαφορετικές περιπτώσεις ασθενειών, για τις οποίες κάποιος θα μπορούσε να περιμένει, από στατιστική άποψη, μία σχετικά κοινή ιατρική αντιμετώπιση σε σχέση με τις διαγνωστικές εξετάσεις και τις θεραπευτικές μεθόδους που απαιτούνται για την ίαση (Fetter, 1985;Hovenga, 1996). Συνεπώς οι ομοειδείς διαγνωστικές ομάδες, είναι ένα σύστημα ταξινόμησης των ασθενών ενός νοσηλευτικού ιδρύματος σε κατηγορίες με παρόμοια κοστολογικά χαρακτηριστικά ως προς την ανάλωση των νοσοκομειακών πόρων. ...
... Obtaining accurate cost information for decision making on strategy, reimbursement tariffs, and management is a fundamental challenge for policymakers, healthcare administrators, and researchers in healthcare accounting (Cardinaels, Roodhooft, & Van Herck, 2004;Cardinaels & Soderstrom, 2013;Eldenburg & Kallapur, 2000;Gil & Hartmann, 2007;Hovenga, 1996;Hsu & Qu, 2012;Pettersen, 2001). The cost accounting system plays a critical role, but it is difficult to design an effective system because healthcare organizations have different information needs; indeed, any effective cost accounting system is based on an understanding of the information that is needed and what it allows us to do (Cannavacciuolo, Illario, Ippolito, & Ponsiglione, 2015). ...
The most important societal challenge is aging, often associated with chronic disease and increased multimorbidity; nevertheless, the prospective cost of an aging society will not be sustainable in terms of health care and social services.
In late 2011, the Campania Regional Government launched a study with the aim of implementing a tariff system for the provision of home and palliative care services.
To define the tariff system, the regional government set up two working groups: one to identify home and palliative care profiles and the other to propose a tariff system for home and palliative care based on the profiles identified. The second group analyzed the average resources absorbed by each of the care profiles identified using a Time-Driven Activity-Based Costing system. The study carried out has two distinguishing features: a) its use to establish a system of tariffs related to services provided over a particular time frame set out in an Individualized Care Plan, and b) the method of calculating the daily cost of care, i.e. the cost of a “standard” day, including access to all the healthcare professionals, albeit with different weighting, required to care for the patient at home. The study identified a prospective tariff system based on the average total resources absorbed according to the different levels of patient complexity rather than historical costs, that, although it refers to a Italian regional context, it highlights a methodology that can be applied in other countries.
... The achievement of relevant and accurate cost information to ground the decisions concerning strategy, pricing and management is a fundamental issue for policy makers who face hospital financing and reimbursement problems, for hospital administrators who pursue internal cost management purposes, and for health policy scholars (Cardinaels et al., 2004;Gil and Hartmann, 2007;Eldenburg and Krishan, 1997;Pettersen, 2001;Hovenga, 1996). This premise implies the critical role of the design and implementation of cost accounting systems in healthcare organizations. ...
Purpose – The purpose of this paper is to set out a methodological framework to investigate how the
integration of an activity-based costing (ABC) logic into the pre-existent accounting system supports
healthcare organizations in identifying the inefficiencies related to their diagnostic therapeutic
pathways (DTP) and related reengineering interventions.
Design/methodology/approach – The BPM-ABC methodological framework has been applied to
the case of a specific surgery pathway, at the Orthopaedic Division of a University Hospital in Italy.
Findings – The case-study described in the paper points out: first, how the Business Process
Management (BPM)-ABC methodology is able to produce significant information about consumed
resources and the costs of the activities, useful to highlight opportunities for DTPs improvement;
second, the barriers related to a pre-existing accounting system based on cost centres that can hinder
the implementation of the BPM-ABC model.
Practical implications – The case study points out the role of the ABC as a management tool for
supporting decision-making processes. The ABC allows inferring information for two purposes. First,
ABC supports a cost containment process as it allows highlighting the most cost-consuming activities
and resources. Second, the ABC allows identifying reengineering paths, distinguishing between
incremental and radical ones.
Originality/value – This study represents a remarkable reference raising the awareness of the
pivotal role accounting systems play in the management of the organizational processes.
Keywords Case studies, Healthcare, Activity-based costing, Business process reengineering
Paper type Case study.
... The achievement of relevant and accurate cost information to ground the decisions concerning strategy, pricing and management is a fundamental issue for policy makers who face hospital financing and reimbursement problems, for hospital administrators who pursue internal cost management purposes, and for health policy scholars (Cardinaels et al., 2004;Gil and Hartmann, 2007;Eldenburg and Krishan, 1997;Pettersen, 2001;Hovenga, 1996). This premise implies the critical role of the design and implementation of cost accounting systems in healthcare organizations. ...
Purpose
The paper sets out a methodological framework to investigate how the integration of an ABC (Activity-Based Costing) logic into the pre-existent accounting system supports healthcare organizations in identifying the inefficiencies related to their Diagnostic Therapeutic Pathways (DTP) and related reengineering interventions.
Design/methodology/approach
The BPM-ABC methodological framework has been applied to the case of a specific surgery pathway, at the Orthopedic Division of a University Hospital in Italy.
Findings
The case-study described in the paper points out: i) how the BPM (Business Process Management)-ABC methodology is able to produce significant information about consumed resources and the costs of the activities, useful to highlight opportunities for DTPs improvement; ii) the barriers related to a pre-existing accounting system based on cost centres that can hinder the implementation of the BPM-ABC model.
Practical implications
The case study points out the role of the ABC as a management tool for supporting decision making processes. The ABC allows inferring information for two purposes. Firstly, ABC supports a cost containment process as it allows highlighting the most cost-consuming activities and resources. Secondly, the ABC allows identifying reengineering paths, distinguishing between incremental and radical ones.
Originality/value
This study represents a remarkable reference raising the awareness of the pivotal role accounting systems play in the management of the organizational processes.
Healthcare is one of the largest sectors for expenditure in any developed economy. In 2019, an average of 8.8% of Gross Domestic Product (GDP) or US$4,097 per person was spent on healthcare across 34 countries according to the Organisation for Economic Cooperation and Development (OECD) [1].
This chapter will explore the role that Health Economics plays in the design and implementation of healthcare methodologies and commences with a discussion on healthcare funding comparisons around the nations of the world.
Next, a model is presented explaining various ways healthcare is funded using two dimensions:
The extent to which clients or patients group together as joint Purchasers, ranging from an individual patient paying out-of-pocket for themselves, through various levels of private insurance, up to “universal healthcare”.
The extent to which the resources of health service providers are aggregated or “bundled” into identifiable Services to be funded or purchased. This ranges from fixed, or expenditure-based funding, through activity-based funding and up to population-based funding.
Each method involves a defined level of both financial and clinical quality risk that must be unpacked, understood, and managed by the medical manager. An understanding of these funding methods and the ability to manage these risks represents an essential knowledge base and skill set for medical administrators and clinical leaders.
An in-depth review of Activity-Based Funding (ABF) follows, as one of the key and enduring methods of healthcare financing.
AbstrakCoder mempengaruhi penerimaan rumah sakit karena kemampuannya dalam menetapkan kode menggunakan ICD untuk mengkode diagnosa dan prosedur yang tercatat didalam dokumen rekam medis. Penelitian ini bertujuan untuk mengetahui perbedaan hasil koding coder di Rumah Sakit Pemerintah X Semarang dan potensi kerugian yang mungkin terjadi. Metode yang digunakan adalah kuantitatif, melibatkan 6 orang coder yang dibagi menjadi 2 kelompok yaitu standar dan uji, berdasarkan masa kerja dan pelatihan yang pernah diikuti. Hasil koding dan besaran klaim antar kelompok dibandingkan. Dari penelitian didapatkan kompetensi coder perlu ditingkatkan karena rerata hasil tarif lebih rendah dari kelompok standar yang tinggi 32,6%, berpotensi menurunkan pendapatan rumah sakit rata-rata sebesar 4,2% dari klaim yang seharusnya diterima. AbstractCoders affect hospital revenue due to their ability to determine specificcode using ICD for diagnoses and procedures stated in medical record. This study aimed to determine the competence of coder in X Hospital and potential losses that may occur. Quantitative method was used in this study, involving 6 coders who were divided into 2 groups: standard and test groups, based on years of experience and followed trainings. Coding results and the amount of the claim were compared between groups. The study showed coder‘s competence still needs to be improved. This was characterized by a high average undercoding result that reached 32.6% and potentially loweringhospital revenue by an average of 4.2% of claims that should be obtainedby the hospital.v
This paper presents the form and validation results of APACHE II, a severity of disease classification system. APACHE II uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status to provide a general measure of severity of disease. An increasing score (range 0 to 71) was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals. This relationship was also found for many common diseases. When APACHE II scores are combined with an accurate description of disease, they can prognostically stratify acutely ill patients and assist investigators comparing the success of new or differing forms of therapy. This scoring index can be used to evaluate the use of hospital resources and compare the efficacy of intensive care in different hospitals or over time.
Measurement of illness severity is required to evaluate diagnostic efficiency of physicians, assess quality of care, understand utilization of health services, design clinical trials, and reimburse hospitals on the basis of output. "Staging" is a method for measuring severity of specific, well-defined diseases. Staging defines discrete points in the course of individual diseases that are clinically detectable, reflect severity in terms of risk of death or residual impairment, and possess clinical significance for prognosis and choice of therapeutic modality. Medical staging criteria have been developed for 420 diagnoses and converted into "coded" criteria for the major diagnostic coding systems. Coded criteria can be efficiently applied to computerized hospital discharge abstracts to derive a comprehensive case-mix classification system. Uses of staging in epidemiologic, case-mix, and utilization analyses are illustrated for diabetes mellitus.
(JAMA 1984;251:637-644)
This study examines the equivalence of the hours of care estimates of four patient classification/workload measurement systems. Although the hours of care estimates of the systems were similar, differences between the estimates could be as great as 4.53 hours per day for the same patient. The researchers developed relational statements that made hours of care estimates equivalent for all systems studied. System differences can have a profound impact on nursing unit and department budgets, if not adjusted.
The Medical Illness Severity Grouping System--called MEDISGRPS--is an admission-oriented patient severity grouping system that uses objective, key clinical findings to place patients in one of five severity groupings. Data from five hospitals indicate that severity level at admission is an important predictor of resource use, is essential for analysis of patients who deteriorate and/or respond poorly to therapy, and is useful to further specify DRGs. Measures of effectiveness and efficiency using MEDISGRPS are suggested.
We describe the new Computerized Severity Index (CSI) that is obtained from an expanded discharge abstract data set, based on a 6th-digit severity addition to the ICD-9-CM coding system. The new 6-digit code book (called ICD-9-CMSA) is used to label existence and severity of each principal and secondary diagnosis. It can be used to produce an overall severity of illness level for each hospital inpatient. The impact of severity-adjusted DRGs on prospective payment and uses of the CSI for assessing quality of care, efficiency, physician practice profiles, and prediction of posthospital resource needs are discussed.
Hospitals are considering adoption of patient classification systems, in part, because of their desire to create a clinically meaningful data base for quality assurance and monitoring. But before they make the substantial financial investment such a system requires, hospital personnel should be sure it is appropriate for their institution. The system should be reliable, medically meaningful, and useful in differentiating cases in which care was poor. The classification components should be easily available from the hospital's standard information. The cost of the system and its impact on staff should also be considered.
Since the adoption of Medicare's Prospective Payment System (PPS), critics have raised concerns about the degree of variation in cost per case due to variability in severity of illness within DRGs. Using hospital (Part A) costs for all Medicare beneficiaries hospitalized in Michigan during 1982, this paper applies multivariate techniques to test the ability of two state-of-the-art case-mix measures to either replace or act as a severity modifier to DRGs. When compared with DRGs, neither Patient Management Categories (PMCs) nor Disease Staging explains any more of the variation in costs. Results show that DRGs explain 33%, while PMCs and Disease Staging explain 26% and 17%, respectively. The use of either alternative in tandem with DRGs explains only 1-2% more of the observed variation; however, both PMCs and Disease Staging identify subgroups of patients with significantly different costs. These findings suggest that the alternatives may prove modestly useful as DRG modifiers by identifying classes of patients that do not belong. More importantly, they offer a measure of "unrelated comorbidity" that may improve the performance of DRGs.