Case Mix Measures: DRGs and Alternatives

Kramer, Paula S.

doi:10.1146/annurev.pu.09.050188.002001

Cited by 25 publications

(8 citation statements)

References 26 publications

(6 reference statements)

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“…Yet, the number of case groups should not exceed a reasonable and manageable limit. Furthermore, increasing predictive ability solely based on adding more variables might risk losing clinical meaningfulness of groupings [ 50 ]. Thus, discussions on how much improvement in predictive power is a criterion for better casemix systems’ performance needs to consider the trade-off between statistical predictive ability and clinical meaningfulness.…”

Section: Discussionmentioning

confidence: 99%

Capturing patients’ needs in casemix: a systematic literature review on the value of adding functioning information in reimbursement systems

Hopfe

Stucki

Marshall

et al. 2015

BMC Health Serv Res

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BackgroundContemporary casemix systems for health services need to ensure that payment rates adequately account for actual resource consumption based on patients’ needs for services. It has been argued that functioning information, as one important determinant of health service provision and resource use, should be taken into account when developing casemix systems. However, there has to date been little systematic collation of the evidence on the extent to which the addition of functioning information into existing casemix systems adds value to those systems with regard to the predictive power and resource variation explained by the groupings of these systems. Thus, the objective of this research was to examine the value of adding functioning information into casemix systems with respect to the prediction of resource use as measured by costs and length of stay.MethodsA systematic literature review was performed. Peer-reviewed studies, published before May 2014 were retrieved from CINAHL, EconLit, Embase, JSTOR, PubMed and Sociological Abstracts using keywords related to functioning (‘Functioning’, ‘Functional status’, ‘Function*, ‘ICF’, ‘International Classification of Functioning, Disability and Health’, ‘Activities of Daily Living’ or ‘ADL’) and casemix systems (‘Casemix’, ‘case mix’, ‘Diagnosis Related Groups’, ‘Function Related Groups’, ‘Resource Utilization Groups’ or ‘AN-SNAP’). In addition, a hand search of reference lists of included articles was conducted. Information about study aims, design, country, setting, methods, outcome variables, study results, and information regarding the authors’ discussion of results, study limitations and implications was extracted.ResultsTen included studies provided evidence demonstrating that adding functioning information into casemix systems improves predictive ability and fosters homogeneity in casemix groups with regard to costs and length of stay. Collection and integration of functioning information varied across studies. Results suggest that, in particular, DRG casemix systems can be improved in predicting resource use and capturing outcomes for frail elderly or severely functioning-impaired patients.ConclusionFurther exploration of the value of adding functioning information into casemix systems is one promising approach to improve casemix systems ability to adequately capture the differences in patient’s needs for services and to better predict resource use.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1277-x) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 99%

Capturing patients’ needs in casemix: a systematic literature review on the value of adding functioning information in reimbursement systems

Hopfe

Stucki

Marshall

et al. 2015

BMC Health Serv Res

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“…The feasibility of a case-mix approach has been demonstrated in a number of healthcare settings, including acute care hospitals (eg, diagnosis-related groups, DRGs) and nursing homes (eg, Resource Utilization Groups [RUG-IV]). 5-7 Notably, while case-mix is used in institutional settings for determining facility payment, in the community setting, case-mix is used to determine the allocation of resources (eg, determining level of service, such as the maximal number of hours) or funding (such as a voucher for services). As the latter is at the level of an individual, and as the availability of natural supports (eg, informal caregivers) can vary, case-mix assignment in community settings should allow for additional discretion in the actual allocation.…”

Section: Introductionmentioning

confidence: 99%

A Case-Mix System for Children and Youth With Developmental Disabilities

Stewart

Celebre

Head³

et al. 2020

Health�Serv�Insights

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Limited funding across health and social service programs presents a challenge regarding how to best match resources to the needs of the population. There is increasing consensus that differences in individual characteristics and care needs should be reflected in variations in service costs, which has led to the development of case-mix systems. The present study sought to develop a new approach to allocate resources among children and youth with intellectual and developmental disabilities (IDD) as part of a system-wide Medicaid payment reform initiative in Arkansas. To develop the system, assessment data collected using the interRAI Child and Youth Mental Health-Developmental Disability instrument was matched to paid service claims. The sample consisted of 346 children and youth with developmental disabilities in the home setting. Using automatic interactions detection, individuals were sorted into unique, clinically relevant groups (ie, based on similar resource use) and a standardized relative measure of the cost of services provided to each group was calculated. The resulting case-mix system has 8 distinct, final groups and explains 30% of the variance in per diem costs. Our analyses indicate that this case-mix classification system could provide the foundation for a future prospective payment system that is centered around stability and equitability in the allocation of limited resources within this vulnerable population.

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“…10,11 This kind of analysis can be undertaken independently of a payment system, although an overarching financial agenda may encourage it, and may stimulate improvements in the accuracy and completeness of the coded data it relies on. 6,11 However, some commentators argue that case-mix classifications designed to predict episode costs for reimbursement purposes have only limited use for quality improvement, either due to the high residual diversity of patients within particular categories, 13 or their inability to provide satisfactory information on predicted health outcomes. 14…”

Section: Introductionmentioning

confidence: 99%