Objective. To examine the hospital coding response to a payment model using a casemix measurement system based on multiple diagnoses and the resulting impact on a hospital cost model. Data Sources. Financial, clinical, and supplementary data for all Ontario short stay hospitals from years 1997 to 2002. Study Design. Disaggregated trends in hospital case-mix growth are examined for five years following the adoption of an inpatient classification system making extensive use of combinations of secondary diagnoses. Hospital case mix is decomposed into base and complexity components. The longitudinal effects of coding variation on a standard hospital payment model are examined in terms of payment accuracy and impact on adjustment factors. Principal Findings. Introduction of the refined case-mix system provided incentives for hospitals to increase reporting of secondary diagnoses and resulted in growth in highest complexity cases that were not matched by increased resource use over time. Despite a pronounced coding response on the part of hospitals, the increase in measured complexity and case mix did not reduce the unexplained variation in hospital unit cost nor did it reduce the reliance on the teaching adjustment factor, a potential proxy for case mix. The main implication was changes in the size and distribution of predicted hospital operating costs. Conclusions. Jurisdictions introducing extensive refinements to standard diagnostic related group (DRG)-type payment systems should consider the effects of induced changes to hospital coding practices. Assessing model performance should include analysis of the robustness of classification systems to hospital-level variation in coding practices. Unanticipated coding effects imply that case-mix models hypothesized to perform well ex ante may not meet expectations ex post.
Ontario cancer programs aim to deliver high-quality nursing care and treatment that is safe for patients and staff. The reality of health care is that financial constraints, inherent in the delivery of care, require that funding mechanisms count not only the cost of drugs, but factors such as pharmacy and nursing human resource costs. While some organizations have developed patient classification systems to measure nursing intensity and workload, these systems apply primarily to inpatient populations, and are fraught with numerous challenges, such as the need for nurses to document to justify the workload required for care. The purpose of this paper is to outline the methodology and engagement of nurses to develop regimen-based resource intensity weights that can be applied to ambulatory chemotherapy suites. The methodology included determination of workload related to nursing time to prepare, teach, counsel and assess patients, as well as time to gather supplies, access lines, monitor, manage adverse reactions, manage symptoms and document care. Resource intensity weights provide better measures of the complexity of care required by cancer patients in ambulatory settings.
Les programmes de cancérologie ontariens se sont fixés comme objectif de dispenser des soins infirmiers de haute qualité et des traitements sécuritaires à la fois pour les patients et pour le personnel. Dans le domaine de la santé, les contraintes financières inhérentes à la prestation des soins exigent que les mécanismes de financement rendent compte non seulement du coût des médicaments mais encore de facteurs tels que les coûts des ressources humaines en pharmacie et en soins infirmiers. Alors que certaines organisations ont élaboré des systèmes de classification des patients afin de mesurer l'intensité des soins infirmiers et la charge de travail des infirmières, ces systèmes s'appliquent principalement aux clientèles hospitalisées et présentent de nombreux défis tels que la nécessité pour les infirmières de documenter la charge de travail exigée par les soins à des fins de justification. Cet article a pour but de tracer les grandes lignes de la méthodologie et de l'implication des infirmières en vue d'élaborer une pondération de la consommation des ressources basée sur les protocoles pouvant être appliquée aux salles de chimiothérapie ambulatoire. La méthodologie inclut la détermination de la charge de travail reliée au temps dont les infirmières ont besoin pour préparer, conseiller et évaluer les patients et leur fournir l'enseignement requis ainsi que le temps nécessaire pour rassembler les fournitures, accéder aux lignes de perfusion, surveiller, gérer les effets indésirables, gérer les symptômes et documenter les soins. La pondération de la consommation des ressources fournit une meilleure mesure de la complexité des soins exigés par les patients atteints de cancer traités en milieu ambulatoire.
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