Transcript 3M_RTI_DHA Stakeholders Meeting_2017-02-08

Agenda
1.
3M Background
2.
DRG Overview
3.
DRG Prerequisites
4.
DRG Benefits & Examples
5.
IR- DRGs
6.
RTI Background
7.
Shadow Billing for Inpatient IR-DRGs
8.
Sensitivity Analyses
9.
Monitoring
10. Adherence to the Projected Timeline
11. Regulation and Compliance
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3M Health Information Systems
Clinical & Economic
Research
Nosology (e.g. Coders)
1,400
U.S.
EMPLOYEES
150 INTERNATIONAL
NLP & Data Scientists
Clinical Informatics
Physician, Nurses
Pharmacists…
CUSTOMERS
HOSPITALS
PHYSICIANS
Over 30 years of expertise in designing,
maintaining and deploying solutions for better
clinical and financial Performance.
PAYERS
REGULATOR
S
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3M Health Information Systems
Experience
30+ years of Experience Implementing & Supporting DRG’s
U.S.A.
- Classification Maintenance for
CMS since 1983
- ICD-9-CM to ICD-10-PCS
- P4P/P4Q initiatives in NY & MD
United Kingdom
- HRG Development (2013)
Germany
- AR-DRG to G-DRG localization
- Calculation of Relative Weights
- InEK MBDS data collection
- Training for Providers & Payers
Regulator
Provider
Payer
Workforce
UAE (Abu Dhabi)
- 3M IR DRG adopted (2010)
- DRG Assurance Training
Chile
- 3M IR DRG adopted (2011)
Australia
- AR DRG development license


More than 10,000 clients in 25+ countries
Expertise in supporting multiple terminologies, classifications and languages
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3M Health Information Systems
•Projects led by 3M
Classification Development & Maintenance
USA
CANADA
UK
AUSTRALIA HONG-KONG
GERMANY
Support for DRG Introduction
BELGIUM
GERMANY HONG-KONG QATAR SINGAPORE SPAIN
CHILE
UA
E
Computation of Relative Weights
GERMANY ITALY
PORTUGAL SINGAPORE SPAIN
Reimbursement and Fee Schedule Development
GERMANY QATAR
USA
Quality and Value-Based Initiatives
GERMANY
SPAIN
USA
Population-Based Initiatives
CANADA
ITALY
SPAIN
USA
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3M Classification and Payment Methodologies
• Expert Driven, Enabling Advanced Variability Analysis
Inpatient & Outpatient
Population Health
Risk Adjusted, Linking Clinical Patterns to Cost
Patient Centered Risk Adjusted Data, Quality & Patient Safety Measures, Total Cost of Care
APR DRGs
EAPGs
IR-DRGs
All Patient
Refined
Diagnosis
Related
Groups
Enhanced
International
Refined
Diagnosis
Related
Groups
Inpatient
Grouper
Severity and
Risk of
Mortality
Ambulatory
Patient
Groups
Outpatient
Grouper
International
Grouper
In & Outpatient
PPCs
CRGs
Clinical Risk
Groups
Health status
Grouper
Potentially
Preventable
PPRs
Potentially
Preventable
Complications
Readmission
s
Identify
preventable
complications
Identify
preventable
readmissions
Value
Index
Score
PPV
Potentially
Preventable
ED Visits
PFEs
PFPs
Patient
Focused
Episodes
Population
Focused
Preventables
Defines 700+
patient
episodes
PPA
Potentially
Preventable
Initial
Admissions
PPS
Potentially
Preventable
Services
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DRG Overview
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Health System Management
Transparency
1. Production Efficiency
2. Quality Management
3. Cost Management
4. Strategic Planning
6
It started with a question…..
How could industrial methods of cost
and quality control be adapted and
applied to the hospital industry?
Thompson to Fetter
Yale University - 1968
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The answer …..
Another question…
“What is the true product of the hospital?”
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Defining Hospital Products
HOSPITAL OPERATIONS
INPUTS
INTERMEDIATE
OUPUTS
PHYSICIAN ORDERS
PRODUCTS
PATIENT DAYS
LABOR
MEALS
MATERIALS
EQUIPMENT
LABORATORY
PROCEDURES
MANAGEMENT
SURGICAL
PROCEDURES
Efficiency
MEDICATIONS
APPENDECTOPMY WITHOUT
COMPLICATIONS, AGE <70
w/o Co-morbidity &
Complications
Effectiveness
DELIVERY
WITHOUT
COMPLICATIONS
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Basic Principals of Diagnosis Related Groups
PATIENT CARE
PATIENT
VARIABLES
HOSPITAL
VARIABLES
 DEMOGRAPHICS (AGE, SEX)
 PRINCIPLE DIAGNOSIS
MINIMUM
 CO-MORBIDITIES
BASIC DATA
SET [MBDS]
 PROCEDURES
 COMPLICATIONS
 DISCHARGE STATUS
GROUPS OF PATIENTS WITH HOMOGENOUS
RESOURCE CONSUMPTION
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DRG as a hospital product
One DRG= One product= One cost
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Basic principals of Diagnosis Related Groups
DRGs are
 Cost homogeneous thus have similar patterns of resource use
 Patients in DRG are not identical
 Predict average level of resource use
 Clinically coherent thus with similar clinical characteristics
 Common organ system, etiology or clinical specialty
 Mutually exclusive
 1 DRG = 1 Patient stay
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Diagnosis Related Groups (DRGs)
Case mix information can tell us how many resources our hospitals
need according to the patients they actually treat
First step in understanding quality issues
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DRG Prerequisites
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Basic principals of Diagnosis Related Groups
 A method to define the “products” of the hospital
 Computed from routinely available data
Age
Sex
Principle diagnosis, complications & co-morbidities:
ICD-10-CM
Procedures: CPT
Discharge status [e.g. transfer, home, death]
Weight on admission [newborns & neo-nates]
Other [e.g. duration of mechanical ventilation]
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Information coded by Clinical Coders
 Principal Diagnosis (definition??)
 Secondary diagnoses
 Co-morbidities relevant to the admission (present on admission)
 Complications – arise following admission
 Procedures performed (therapeutic & diagnostic)
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Importance of Data Quality
 Documentation :
Specificity, Completeness, Timeliness
 Coding:
Accuracy, Consistency, Completeness
 Abstracted Data :
Validated
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Complete Documentation

Correct Medical Coding

Correct DRG

Appropriate Reimbursement/Funding
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DRG Benefits & Examples
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You cannot manage what you do not measure
Improve
Planning and
Budgeting
Analyze
Define
Reporting and
Analytics
Data and Metrics
Monitor
Dashboards and
Scorecards
Minimum Basic
Dataset
KPIs
Length of Stay
Mortality
Case Mix Index
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Purpose of a DRG system
 To provide a classification system that is a better basis for:
 Management
 Budgeting
 Payment
 Profiling
 Benchmarking
 Clinical research
 Quality reporting
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Balancing Cost and Quality
Cost
Quality
Providers
Payers
Consumer
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Case Mix Analysis
It is all about comparing data
The Ministry compares
the Regions...
The Regions compare
the Hospitals...
The Hospitals compare
the Departments...
The Departments compare
the Physicians...
Physicians compare…
the Patients
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Case-Mix Index (CMI)
 A measure of the relative costliness of treating patients in a hospital
 Case mix index is calculated by:
 SUM (count * relative value) for each DRG
total count
 An index of 1.15 means that the hospital’s patients are 15% more costly than
average
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Casemix DRG’s
A Clinical Tool To Manage Resources and Control Quality
Coding
Grouping
Accurately
Benchmarking /
describes the
DRG
patient activity for
Budgeting /
Consolidates the
the encounter
large and varied
Funding
set of descriptors
Clinical Coding
Classifications
to manageable
groups
•ICD-9-CM
•ICD-9
•ICD-10; ICD-10-AM
•ICPM, CPT, OPCS-4
•ICD-10-CM /PCS
DRG Classifications
•HCFA DRG’s
Uses case mix to
compare hospitals or
resource allocation
model among the
groups
•AP-DRG’s
DRG Based Models
•APR-DRG’S
•Global Allocation
•AN-DRG’s & AR-DRG’s
•Per DRG Allocation
•IR-DRG’s
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Top 20 Most Common DRGs
DRG
014142
146101
021301
014141
131201
146102
101201
061131
071141
061141
131202
064181
051152
014143
014132
074141
091501
051151
054101
014131
DRG Description
IM CEREBROVASCULAR ACCIDENT WITH INFARCT w/CC
IP CESAREAN DELIVERY
IP INTRAOCULAR & LENS PROCEDURES
IM CEREBROVASCULAR ACCIDENT WITH INFARCT
IP UTERINE & ADNEXAL PROCEDURES
IP CESAREAN DELIVERY w/CC
IP THYROID, PARATHYROID & THYROGLOSSAL DUCT PROCEDURES
IP APPENDICEAL PROCEDURES
IP LAPAROSCOPIC CHOLECYSTECTOMY
IP INGUINAL & FEMORAL HERNIA PROCEDURES
IP UTERINE & ADNEXAL PROCEDURES w/CC
IM OTHER DIGESTIVE SYSTEM DIAGNOSES
IP CARDIAC CATHETERIZATION w/CC
IM CEREBROVASCULAR ACCIDENT WITH INFARCT w/MCC
IM NON-TRAUMATIC INTRACRANIAL HEMORRHAGE w/CC
IM OTHER BILIARY TRACT DISORDERS
IP BREAST PROCEDURES
IP CARDIAC CATHETERIZATION
IM ACUTE MYOCARDIAL INFARCTION
IM NON-TRAUMATIC INTRACRANIAL HEMORRHAGE
Count Percent
7349
8.2%
6634
7.4%
5932
6.6%
5591
6.3%
4958
5.5%
4063
4.5%
3000
3.4%
2954
3.3%
2624
2.9%
2420
2.7%
1895
2.1%
1505
1.7%
1430
1.6%
1289
1.4%
1258
1.4%
1235
1.4%
1232
1.4%
1177
1.3%
1111
1.2%
1084
1.2%
Cumm
Percent
8%
16%
22%
29%
34%
39%
42%
45%
48%
51%
53%
55%
56%
58%
59%
61%
62%
63%
64%
66%
Two thirds of 89,000 cases were grouped into the
top 20 DRGs
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Length of Stay
0.0
0
ChaoYang
BeiDa
Hosp 309
7.4
11.3
11.4
11.6
11.9
12.0
12.3
10.5
9.0
14.1
14.1
14.4
14.4
14.5
13.2
10.9
9.0
10
Union
Tong Ren
AirForce
Sino-Japan
An Zhen
Hai Dian
Police
Xuan Wu
People
Military
Shi Ji Tan
Fu Xing
Friendship
6th
Tian Tan
15.5
15.8
15.0
15
Hai Jun
Ji Shui Tan
He Ping Li
Er Pao
Hospital Length of Stay
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600
20
500
400
300
200
5
100
Number of Patients per Hospital
(Line)
26.0
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Average LOS Comparison by Hospital for DRG
"Laproscopic Cholecystectomy"
700
0
Hospital
Num Patients
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LOS Distribution
Hospital - H504
DRG - 081601 CONNECTIVE TISS PROC
80
70
LOS (days)
60
50
Cases above
High Trim:
High Trim
2.95%
40
30
20
Average
10
Low Trim
0
0
100
200
300
400
500
600
700
800
Patients
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LOS Distribution
Hospital - H505
DRG - 081601 CONNECTIVE TISS PROC
80
LOS (days)
70
60
Cases above
the High Trim :
0.82%
High Trim
50
40
30
20
Average
10
Low Trim
0
0
500
1000
1500
2000
2500
Patients
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IR DRGs
(International Refined Diagnosis Related
Groups)
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Examples of DRG Family
• “Medicare”; MS-DRGs – original 1983
– Includes Multiple Trauma, Transplants, Tracheostomy. Focus on Over 65 Population
• All Patient; AP-DRGs
– Adds DRGs for Newborns, Major Complications and Co-morbidities, Intended for a General
Population
• All Patient Refined; APR-DRGs
– Based on AP-DRGs, Yale Refinements, CMS updates - Adds Four Severity Levels Based on Severity
of Illness Risk of Mortality, and Resource Intensity--Minor, Moderate, Major, Extreme
• International Refined; IR-DRGs
– Based on AP-DRGs,Yale Refinements, CMS updates and the APR-DRGs - has Three Severity Levels
Based on Severity of Illness-- Non-Complications, With Complications and with Major
Complications
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DRG development
1st Generation
2nd Generation
GHS
2006
IR-DRG
3rd Generation
IR-DRG 2.x
MS-DRG
G-DRG
2008
2003
4th Generation
2004
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Conceptual Framework
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Procedure Classes
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“Yes, But My Patients Are Sicker”
Led to Inpatient Severity Levels
 Minor: Uncomplicated Diabetes
Mod: Diabetes with renal complications
Major: Diabetes with ketoacidosis
 Minor: Difficulty breathing
Mod: Emphysema
Major: Respiratory Failure
 Minor: Hypertrophy of kidney
Mod: Chronic Renal Failure
Major: Acute Renal Failure
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IR DRG Classification SOI/ROM
MDC Major Diagnostic Category
IR DRG
Three Severity of Illness Subclasses
Three Risk of Mortality Subclasses
1.
Minor
Hypertrophy of kidney
1.
Minor
Impaired renal function
2.
Moderate
Chronic renal failure
2.
Moderate
Chronic renal failure
3.
Major
Acute renal failure
3.
Major
Acute renal failure
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SOI and ROM are Independent …..
The severity of illness and risk of mortality subclass are calculated separately
and may be different from each other.
SOI = 3
Significant Organ Decomposition
Acute Cholecystitis
ROM = 1
Low risk of
mortality
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IR DRG Severity and Mortality Risk Adjustment for Heart
Insufficiency
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Basic Principals of DRGs
PATIENT CARE
HOSPITAL VARIABLES
PATIENT VARIABLES
 DEMOGRAPHICS (AGE,
SEX)
 PRINCIPLE DIAGNOSIS
 CO-MORBIDITIES
 PROCEDURES
 COMPLICATIONS
 DISCHARGE STATUS
MINIMAL BASIC
DATA SET
[MBDS]
GROUPS OF PATIENTS WITH HOMOGENOUS
RESOURCE CONSUMPTION
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Research Triangle Institute (RTI)
Michael Trisolini
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RTI – Who we are
RTI is an independent,
nonprofit institute that
provides research,
development, and technical
services to government and
commercial clients worldwide.
Our mission is to improve the
human condition by turning
knowledge into practice.
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RTI Global Presence – Workforce
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RTI Health Research, Development, and Technical
Service Areas
• Global health
• Health economics & financing
• Health care quality
• Public health
• Health planning and policy
• Health information technology
• Health communication
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• Epidemiology
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DHA Project Overview
Phase I Timeline – February 2015 to July 2016
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Planning Phase
• Current Situation Analysis
• Round Table Meeting
• Implementation Plan
Implementation
Planning
• Five-year Plan for 2016 to 2020
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DHA Project Overview (cont.)
Phase II Timeline – August 2016 to July 2018
IR-DRGs
Implementation
Monitoring, Policy,
Training
10
• Dubai Health Care Cost Index
• IR-DRG Parameters & Implementation
• IR-DRG Monitoring Indicators
• Policy Briefs
• Training for DHA Staff
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Shadow Billing for Inpatient IR-DRGs
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Projected Timeline
1st Feb
2017
1st July 2017
1st
April 2018
• Shadow Billing Phase I
• IR-DRG codes on eClaimLink
• Shadow Billing Phase II
• Estimated IR-DRG price added to
claims
• Not affecting payments
• IR-DRG Prices Phase
• Affecting hospital payments
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Shadow Billing Goals
Phase-in Transition Period – Experience other countries and in Abu
Dhabi strongly suggest an IR-DRG transition period of 12 months or
more
Transition period enables hospitals, insurance companies, and other
stakeholders time to adjust systems, staff and operations to the new
financial incentives under IR-DRGs that are very different from the
current fee-for-service payment system
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Shadow Billing Goals
Start with Shadow Billing -- Include IR-DRGs on hospital inpatient
claims for information only and not for payment for 12 months or
more, while continuing fee-for-service payment to hospitals
Shadow billing allows hospitals, insurance companies, and other
stakeholders time to understand the details of IR-DRG payment
system requirements and the impact of the new payment system
on them
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Shadow Billing Goals (cont.)
 Shadow billing allows time to adjust hospital systems, staff, financial
management, and clinical operations. For example:
Cost analysis by IR-DRG
Medical records coding staff training
Clinical staff managing hospital ancillary services utilization for
efficiency versus for increasing billings
At the same time, while managing for efficiency, also avoid underutilization of hospital services needed by patients
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Goals of IR-DRG Payment
Goals of Bundling Services in IR-DRGs for Hospital Inpatient Payment
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
Remove financial incentives for overtreatment or increasing
volumes of care – laboratory tests, radiology, length of stay (LOS) in
hospital – that exist in fee-for-service payment

Provide financial rewards for efficient hospitals providing care that
is less costly than the fixed DRG payment per inpatient stay

Simplify hospital billing for inpatient care by reducing the number of
units of service billed, simplify utilization review, fewer denials

Provide flexibility for future implementation of paying for quality
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What do IR-DRG Payments Cover?
All Inpatient Hospital Services Are
Covered by a DRG Payment,
Including:
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•
•
•
•
•
•
•
•
•
•
Physician care
Nursing care
Technician services
Therapies
Radiology
Laboratory
Pharmaceuticals
Room
Meals
And Others…
52
Shadow Billing – Phase I
IR-DRG coding – Each inpatient stay needs to have an IR-DRG
assigned using the 3M grouper software
ICD-10 and CPT coding – An IR-DRG system depends upon
accurate coding of all hospital services provided in inpatient
hospital stays, and diagnoses, so hospital coding needs to be
reviewed and upgraded if needed
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Shadow Billing – Phase I (cont.)
• Standardizing payment terminology and claims data coding for
Encounter Type – Defining key measures of hospital use and
cost
– For example, define what constitutes an inpatient stay that
will be paid using IR-DRGs, versus outpatient care
– Is one overnight in the hospital required to define an
inpatient stay, or patient’s presence in the hospital for the
midnight census, or formal admission by a doctor to define an
inpatient stay
– Other rules, regulations, data dictionaries for claims data
coding and IR-DRG payment
– Consultation and discussion among stakeholders
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Shadow Billing – Phase I (cont.)
 Ensuring other claims data fields are defined in detail and coding
is complete and consistent across all hospitals
 Ensuring that patient demographic data and unique identifiers
are complete and consistent in all member registries for health
insurance companies
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Shadow Billing – Phase II
 Estimated payments added to claims for information only to
provide hospitals with information on the new IR-DRG payment
system, not affecting hospital payment that continues under feefor-service
 Enables hospitals time to adjust systems, staff, financial
management, and clinical operations to the new types of
payment information and financial incentives under the IR-DRG
system
Consultation and discussion among stakeholders
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Sensitivity Analyses
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Sensitivity Analyses Goals and Methods
•To assess the planned Dubai IR-DRG payment system for biases and
understand the potential effects of the IR-DRG implementation on the
Dubai health care system
•Conducted at the hospital, insurer, IR-DRG, and healthcare sector levels
during the shadow billing period initially, and also continuing
•Use DHA’s eClaimLink claims data and IR-DRG payment calculation
parameters developed to reflect the Dubai health care system
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Types of Sensitivity Analyses
Overall Dubai Health
Care System
Compare overall total
payments made to all
hospitals in Dubai under the
current fee-for-service (FFS)
payment system to overall
total payments that all
hospitals would receive using
the IR-DRG payment system.
Dubai Geographic Areas
Compare overall total
payments made to all
hospitals in different
geographic areas of Dubai
(e.g. Jumeirah vs. Karama)
under the current FFS
payment system and under
the IR-DRG payment system.
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Types of Sensitivity Analyses (cont.)
Dubai IR-DRGs
Compare overall payments
and per by IR-DRG admission
payments made under the
current FFS system and
under the proposed IR-DRG
system.
Dubai Hospitals
Compare overall payments
and per admission IR-DRG
payments made to individual
hospitals in Dubai by hospital
under FFS and under the IRDRG system.
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Types of Sensitivity Analyses (cont.)
Dubai Insurers
Compare overall and per admission IR-DRG payments made
by health insurance company under both the current FFS
payment system and under the IR-DRG system.
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Monitoring
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Need for Monitoring IR-DRGs by DHA
 Incentives for increasing the number of hospital admissions to increase
hospital revenue from additional IR-DRG payments
 Incentives for decreasing services and quality of care for patients to reduce
hospital costs per admissions to increase profits in relation to the fixed IRDRG payment per admission
 Incentives for upcoding CPT procedure codes and ICD-10 diagnosis codes in
hospital inpatient claims to move to IR-DRG with higher payment rate
(increase severity adjuster)
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Types of Monitoring
All hospitals –
Dubai health
sector-wide
Individual
Dubai hospitals
Individual
Dubai IR-DRGs
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Monitoring 1 – Dubai Health Sector-wide
 Trends over time – hospital admissions, readmissions, average length of
stay, transfers of patients to other hospitals
 New hospital openings, hospital closures, hospital services added, hospital
services dropped
 Patient safety events – hospital acquired conditions (HACs), patient safety
indicators (PSIs), never events, hospital acquired infections (HAIs)
 Changes in CPT procedure codes, ICD-10 diagnosis codes, average case-mix
 Medical records audits of procedure codes, diagnosis codes
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Monitoring 2 – Individual Dubai Hospitals
 Trends over time – individual hospital payments, individual hospital case-mix,
individual hospital occupancy rate, average length of stay, number of ICU
days
 Starting or stopping hospital admissions for specific IR-DRGs
 Changes in the numbers of outpatient procedures, outpatient visits, ED visits
 Medical records audits of procedure codes, diagnosis codes, that are
included in the claims data and used to assign IR-DRGs and severity of illness
(SOI) levels for payment
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Monitoring 3 – Individual Dubai IR-DRGs
Trends over time
 Number of times billed per month overall for high
volume IR-DRGs,
 Number of times billed per month by each individual
hospital for high volume IR-DRGs,
 Changes in severity of illness levels (SOI) billed for
high volume DRGs
Starting or stopping billing for specific IR-DRGs
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Regulation and Compliance
68
Adherence to the Projected Timeline
1st Feb
2017
• Shadow Billing Phase I
• IR-DRG codes on eClaimLink
1st July 2017
• Shadow Billing Phase II
• Estimated IR-DRG price added to
claims
• Not affecting payments
1st April 2018
• IR-DRG Prices Phase
• Affecting hospital payments
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Regulation and Compliance
Failure to complete shadow billing will have a direct impact on parameters
that are vital to billing using the IR-DRG system.
As a result….
From 1st of March, claims submitted to eClaimLink will be rejected if DRG
codes are not included
Technically, the DRG code will be mandatory on the claim schema.
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Q&A
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