A Multi-Level System of Performance Evaluation Using Diagnosis-Related Groups for Cost Containment

This study aims to develop a performance evaluation system that can facilitate performance evaluation at region, hospital, and department levels to enable better cost management for sustainable development. A multi-level system of performance evaluation informs a hierarchical assessment of cost management from regions to hospitals to departments using diagnosis-related group (DRGs). Various metrics are developed employing the variances between targets and actuals where targets are determined from two perspectives: benchmarking using external regional prices and change management using internal data. Targets for the latter are statistically based and specifically incorporate variability. The model is applied to two hospitals, twenty departments, nine DRGs and 1071 inpatients. The analyses indicate that the approach can provide a practical evaluation tool that allows for particular characteristics at multiple levels. The system provides macro-micro and external-internal perspectives in performance, enabling high-level variances to be decomposed thereby identifying sources of performance variability and financial impact.

[1]  Ludwig Kuntz,et al.  Separate and Concentrate: Accounting for Patient Complexity in General Hospitals , 2019, Manag. Sci..

[2]  T. Hagen,et al.  Reimbursement systems, organisational forms and patient selection: Evidence from day surgery in Norway , 2009, Health Economics, Policy and Law.

[3]  P. Kung,et al.  Characteristics and related factors of emergency department visits, readmission, and hospital transfers of inpatients under a DRG-based payment system: A nationwide cohort study , 2020, PloS one.

[4]  Suping Wang,et al.  Impacts of Hospital Payment Based on Diagnosis Related Groups (DRGs) with Global Budget on Resource Use and Quality of Care: A Case Study in China , 2019, Iranian journal of public health.

[5]  G. Palmer,et al.  Evaluation of the Performance of Diagnosis-Related Groups and Similar Casemix Systems: Methodological Issues , 2001 .

[6]  Hayoung Park,et al.  Measuring Case-Mix Complexity of Tertiary Care Hospitals Using DRGs , 2004, Health care management science.

[7]  G. Palmer,et al.  Evaluation of the performance of diagnosis-related groups and similar casemix systems: methodological issues , 2001, Health services management research.

[8]  A. He.  Is the Chinese Health Bureaucracy Incapable of Leading Healthcare Reforms?: The Case of Fujian Province , 2012, China: An International Journal.

[9]  Antonio Vera,et al.  DRG cost weight volatility and hospital performance , 2008, OR Spectr..

[10]  S. Suthummanon,et al.  DRG-Based Cost Minimization Models: Applications in a Hospital Environment , 2004, Health care management science.

[11]  A. Geissler,et al.  DRG systems in Europe: variations in cost accounting systems among 12 countries. , 2014, European journal of public health.

[12]  R. Busse,et al.  chapter three Understanding DRGs and DRG-based hospital payment in Europe , 2013 .

[13]  P D Phelan,et al.  DRG cost weights — getting it right , 1998, The Medical journal of Australia.

[14]  X. Castells,et al.  Relationship between hospital structural level and length of stay outliers. Implications for hospital payment systems. , 2004, Health policy.

[15]  C. McDermott,et al.  Average surgeon-level volume and hospital performance , 2016 .

[16]  M. Wiley,et al.  Hospital Payment Mechanism: theory and practice in transition countries , 2002 .

[17]  S. Burwell,et al.  Setting value-based payment goals--HHS efforts to improve U.S. health care. , 2015, The New England journal of medicine.

[18]  A Briggs,et al.  The Distribution of Health Care Costs and Their Statistical Analysis for Economic Evaluation , 1998, Journal of health services research & policy.

[19]  Weiyan Jian,et al.  Performance evaluation of inpatient service in Beijing: a horizontal comparison with risk adjustment based on Diagnosis Related Groups , 2009, BMC health services research.

[20]  C. Doran,et al.  Investigating DRG cost weights for hospitals in middle income countries. , 2009, The International journal of health planning and management.

[21]  V. Mishra,et al.  A comparison of actual cost, DRG-based cost, and hospital reimbursement for liver transplant patients , 2002, Transplant international : official journal of the European Society for Organ Transplantation.

[22]  Carine Milcent.  From downcoding to upcoding: DRG based payment in hospitals , 2020, International Journal of Health Economics and Management.

[23]  R. Ellis,et al.  Creaming, skimping and dumping: provider competition on the intensive and extensive margins. , 1998, Journal of health economics.

[24]  Bogdan C. Bichescu,et al.  Benefits and implications of competing on process excellence: Evidence from California hospitals , 2018, International Journal of Production Economics.

[25]  A. Epstein,et al.  Pay for performance at the tipping point. , 2007, The New England journal of medicine.

[26]  Nadja Kairies-Schwarz,et al.  Performance Pay in Hospitals: An Experiment on Bonus–Malus Incentives , 2020, International journal of environmental research and public health.

[27]  Robert B. Fetter,et al.  Diagnosis Related Groups: Understanding Hospital Performance , 1991 .

[28]  M. Büchler,et al.  Cost Distribution of Orthotopic Liver Transplantation: Single-Center Analysis under DRG-Based Reimbursement , 2005, Transplantation.

[29]  H. Fang,et al.  Containing medical expenditure: lessons from reform of Beijing public hospitals , 2019, BMJ.

[30]  Richard J. Boucherie,et al.  Designing cyclic appointment schedules for outpatient clinics with scheduled and unscheduled patient arrivals , 2011, Perform. Evaluation.

[31]  M. Wolkewitz,et al.  The impact of hospital-acquired infections on the patient-level reimbursement-cost relationship in a DRG-based hospital payment system , 2019, International Journal of Health Economics and Management.

[32]  A. W. Willsmore.  Accounting for management control , 1971 .

[33]  Timothy J. Vogus,et al.  Safety in Numbers: The Development of Leapfrog’s Composite Patient Safety Score for U.S. Hospitals , 2014, Journal of patient safety.

[34]  S. Ueng,et al.  Effectiveness of a multi-faceted intervention among elementary school children , 2019, Medicine.

[35]  S. Boes,et al.  Assessment of the introduction of DRG-based reimbursement in Switzerland: Evidence on the short-term effects on length of stay compliance in university hospitals. , 2021, Health policy.

[36]  Margaret Holmes-Rovner,et al.  Estimating mean hospital cost as a function of length of stay and patient characteristics. , 2003, Health economics.

[37]  Terri Jackson,et al.  Analysis of cost outliers within APR-DRGs in a Belgian general hospital: two complementary approaches. , 2006, Health policy.

[38]  X. Ji,et al.  Performance assessment of the inpatient medical services of a clinical subspecialty , 2018, Medicine.

[39]  F. Cots,et al.  Diagnosis related groups in Europe: moving towards transparency, efficiency, and quality in hospitals? , 2013, BMJ.

[40]  M. You,et al.  Evaluation of Health Policy Governance in the Introduction of the New DRG-Based Hospital Payment System from Interviews with Policy Elites in South Korea , 2020, International journal of environmental research and public health.

[41]  X. Castells,et al.  Relevance of Outlier Cases in Case Mix Systems and Evaluation of Trimming Methods , 2003, Health care management science.

[42]  K. Chan,et al.  Beijing's diagnosis-related group payment reform pilot: Impact on quality of acute myocardial infarction care. , 2019, Social science & medicine.

[43]  Monika Raulinajtys-Grzybek.  Cost accounting models used for price-setting of health services: an international review. , 2014, Health policy.

[44]  F. Rutten,et al.  Comparing methodologies for the cost estimation of hospital services , 2009, The European Journal of Health Economics.

[45]  Jonas Schreyögg,et al.  Cost accounting to determine prices: How well do prices reflect costs in the German DRG-system? , 2006, Health care management science.