Impacts of Diagnosis-Related Groups Payment on the Healthcare Providers' Behavior in China: A Cross-Sectional Study Among Physicians

Impact of Diagnosis-Related Groups (DRG) reform on cost homogeneity of treatment for patients with malignant tumours

The cost fluctuations associated with chemotherapy, radiotherapy, and immunotherapy, as primary modalities for treating malignant tumors, are closely related to medical decision-making and impose financial burdens on patients. In response to these challenges, China has implemented the Diagnosis-Related Group (DRG) payment system to standardize costs and control expenditures. This study collected hospitalization data from patients with malignant tumors who received chemotherapy, radiotherapy, and immunotherapy at Hospital H from 2018 to 2022. The dataset was segmented into two groups: the intervention group, treated with traditional Chinese medicine (TCM) alongside standard therapies, and the control group, treated with standard therapies alone. Changes and trends in hospitalization costs under the DRG policy were analyzed using propensity-score matching (PSM), standard deviation (SD), interquartile range (IQR), and concentration index (CI). Findings showed a decreasing trend in the standard deviation of hospitalization costs across all treatment modalities. Radiotherapy exhibited the most significant decrease, with costs reducing by 2547.37 CNY in the control group and 7387.35 CNY in the intervention group. Following the DRG implementation, the concentration indexes for chemotherapy and radiotherapy increased, while those for immunotherapy did not exhibit this pattern. Costs were more concentrated in patients who did not receive TCM treatment. In summary, DRG reform positively impacted the cost homogeneity of inpatient treatments for malignant tumors, particularly in the control group not receiving TCM treatment. The effects of DRG reform varied across different treatment modalities. Although short-term fluctuations in hospitalization costs may occur, initial evidence during the study period shows the positive impact of DRG reform on cost homogeneity.

Does the Diagnosis-Intervention Packet Payment Reform Impact Medical Costs, Quality, and Medical Service Capacity in Secondary and Tertiary Hospitals? A Difference-in-Differences Analysis Based on a Province in Northwest China

Purpose

To control medical costs and regulate the behavior of providers, China has formed an original widely piloted case-based payment under the regional global budget, called the Diagnosis-Intervention Packet (DIP). This study aimed to evaluated the impact of the DIP payment reform on medical costs, quality of care, and medical service capacity in a less-developed pilot city in Northwest China.

Patients and Methods

We used the de-identified case-level discharge data of hospitalized patients from January 2021 to June 2022 in pilot and control cities located in the same province. We performed difference-in-differences (DID) analysis to examine the differential impact of the DIP reform for the entire sample and between secondary and tertiary hospitals.

Results

The DIP payment reform resulted in a significant decrease of total expenditure per case in the entire sample (5.5%, P < 0.01) and tertiary hospitals (9.3%, P < 0.01). In-hospital mortality rate decreased significantly in tertiary hospitals (negligible in size, P < 0.05), as did all-cause readmission rate within 30 days in the entire sample (1.1 percentage points, P < 0.01) and secondary hospitals (1.4 percentage points, P < 0.01). Proportion of severe patients increased significantly in the entire sample (1.2 percentage points, P < 0.05) and tertiary hospitals (2.5 percentage points, P < 0.01). We did not find the DIP reform was associated with a significant change in relative weight per case.

Conclusion

The DIP payment reform in the less-developed pilot city achieved short-term success in controlling medical costs without sacrificing the quality of care for the entire sample. Compared with secondary hospitals, tertiary hospitals experienced a greater decline in medical costs and received more severe patients. These findings hold lessons for less developed countries or areas to implement case-based payments and remind them of the variations between different levels of hospitals.

Unraveling the effects of DIP payment reform on inpatient healthcare: insights into impacts and challenges

BACKGROUND

The Diagnosis-Intervention Packet (DIP) payment system, initiated by China's National Healthcare Security Administration, is designed to enhance healthcare efficiency and manage rising healthcare costs. This study aims to evaluate the impact of the DIP payment reform on inpatient care in a specialized obstetrics and gynecology hospital, with a focus on its implications for various patient groups.

METHODS

To assess the DIP policy's effects, we employed the Difference-in-Differences (DID) approach. This method was used to analyze changes in total hospital costs and Length of Stay (LOS) across different patient groups, particularly within select DIP categories. The study involved a comprehensive examination of the DIP policy's influence pre- and post-implementation.

RESULTS

Our findings indicate that the implementation of the DIP policy led to a significant increase in both total costs and LOS for the insured group relative to the self-paying group. The study further identified variations within DIP groups both before and after the reform. In-depth analysis of specific disease groups revealed that the insured group experienced notably higher total costs and LOS compared to the self-paying group.

CONCLUSIONS

The DIP reform has led to several challenges, including upcoding and diagnostic ambiguity, because of the pursuit of higher reimbursements. These findings underscore the necessity for continuous improvement of the DIP payment system to effectively tackle these challenges and optimize healthcare delivery and cost management.

Evaluating the effect of health insurance reform on health equity and financial protection for elderly in low- and middle-income countries: evidences from China

BACKGROUND

To achieve Universal Health Coverage (UHC), China have implemented health system reform to expend health coverage and improve health equity. Scholars have explored the implementing effect of this health reform, but gaps remained in health care received by elderly. This study aims to assess the effect of implementing health insurance payment reform on health care received by elderly, as well as to evaluate its effect on cost sharing to identify whether improve financial protection of elderly under this reform.

METHODS

We identified hospitalization of 46,714 elderly with cerebral infarction from 2013 to 2023. To examine the determinant role played by DRGs payment reform in healthcare for elderly and their financial protection, this study employs the OLS linear regression model for analysis. In the robustness checks, we validated the baseline results through several methods, including excluding the data from the initial implementation of the reform (2021), reducing the impact of the pandemic, and exploring the group effects of different demographic characteristics.

RESULTS

The findings proposed that implementing DRGs payment reduces drug expenses but increases treatment expense of chronic disease for elderly in China. This exacerbates healthcare costs for elderly patients and seems to be contrary to the original purpose of health care reform. Additionally, the implementation of DRGs payment reduced the spending of medical insurance fund, while increased the out-of-pocket of patients, revealing a shift in health care expenses from health insurance fund to out-of-pocket.

CONCLUSIONS

This study shares the lessons from China's health reform and provides enlightenment on how to effective implement health reform to improve health equity and achieve UHC in such low- and middle-income countries facing challenges in health financing.

How does diagnosis-related group payment impact the health care received by rural residents? Lessons learned from China

OBJECTIVES

There is growing evidence that differences exist between rural and urban residents in terms of health, access to care and the quality of health care received, especially in low- and middle-income countries (LMICs). To improve health equity and the performance of health systems, a diagnosis-related group (DRG) payment system has been introduced in many LMICs to reduce financial risk and improve the quality of health care. The aim of this study was to examine the impact of DRG payments on the health care received by rural residents in China, and to help policymakers identify and design implementation strategies for DRG payment systems for rural residents in LMICs.

STUDY DESIGN

Health impact assessment.

METHODS

This study compared the impact of DRG payments on the healthcare received by rural residents in China between the pre- and post-reform periods by applying a difference-in-difference (DID) methodology. The study population included individuals with three common conditions; namely, cerebral infarction, transient ischaemic attack (TIA), and vertebrobasilar insufficiency (VBI). Data on patient medical insurance type were assessed, and those who did not have rural insurance were excluded.

RESULTS

This study included 13,088 patients. In total, 33.63% were from Guangdong (n = 4401), 38.21% were from Shandong (n = 5002), and 28.16% were from Guangxi (n = 3685). The DID results showed that the implementation of DRGs was positively associated with hospitalization expense (β4 = 0.265, P = 0.000), treatment expense (β4 = 0.343, P = 0.002), drug expense (β4 = 0.607, P = 0.000), the spending of medical insurance funds (β4 = 0.711, P = 0.000) and out-of-pocket costs (β4 = 0.164, P = 0.000).

CONCLUSIONS

The findings of this study suggest that the implementation of DRG payments increases health care costs and the financial burden on health systems and rural patients in LMICs. This is contrary to the original intention of implementing the DRG payment system.

Exploring hot topics and evolutionary paths in the Diagnosis-Related Groups (DRGs) field: a comparative study using LDA modeling

BACKGROUND

This study reviews the research status of Diagnosis-related groups (DRGs) payment system in China and globally by analyzing topical issues in this field and exploring the evolutionary trends of DRGs in different developmental stages.

METHODS

Abstracts of relevant literature in the field of DRGs were extracted from the China National Knowledge Infrastructure (CNKI) database and the Web of Science (WoS) core database and used as text data. A probabilistic distribution-based Latent Dirichlet Allocation (LDA) topic model was applied to mine the text topics. Topical issues were determined by topic intensity, and the cosine similarity of the topics in adjacent stages was calculated to analyze the topic evolution trend.

RESULTS

A total of 6,758 English articles and 3,321 Chinese articles were included. Foreign research on DRGs focuses on grouping optimization, implementation effects, and influencing factors, whereas research topics in China focus on grouping and payment mechanism establishment, medical cost change evaluation, medical quality control, and performance management reform exploration.

CONCLUSIONS

Currently, the field of DRGs in China is developing rapidly and attracting deepening research. However, the implementation depth of research in China remains insufficient compared with the in-depth research conducted abroad.

Effects of a Diagnosis-Related Group Payment Reform on Length and Costs of Hospitalization in Sichuan, China: A Synthetic Control Study

Background

Diagnosis-related group (DRG) payment policies are increasingly recognized as crucial instruments for addressing health care overprovision and escalating health care costs. The synthetic control method (SCM) has emerged as a robust tool for evaluating the efficacy of health policies worldwide.

Methods

This study focused on Panzhihua city in Sichuan Province, a pilot city for DRG payment reform implementation, serving as the treatment group. In contrast, 20 nonpilot cities within the province were utilized as potential control units. A counterfactual control group was constructed to evaluate the changes in average inpatient stay duration and health care organization costs following the DRG payment reform initiated in 2018.

Results

Focusing on Panzhihua, Sichuan Province, the analysis reveals that following the reform in March 2018, the average length of hospital stay in Panzhihua decreased by 1.35 days during 2019-2021. Additionally, the average cost per hospitalization dropped by 855.48 RMB, the average cost of medication per hospitalization decreased by 68.51 RMB, and the average cost of diagnostic and therapeutic procedures per hospitalization declined by 136.37 RMB. While global evidence backs DRGs for efficiency and cost reduction, challenges persist in addressing emerging issues like new conditions.

Conclusion

Since its introduction in 2018, the DRG payment reform in Sichuan Province has effectively reduced both the duration of hospital stays and the operational costs of health care facilities. However, potential drawbacks include compromised service quality and an elevated risk of patient readmission, indicating a need for further refinement in the implementation of DRG payment reforms in China.

Impacts of DRG-Based Prepayment Reform on the Cost and Quality of Patients with Neurologic Disorders: Evidence from a Quasi-Experimental Analysis in Beijing, China

Purpose

As one of the pioneering pilot cities in China's extensive Diagnosis Related Groups (DRG) -based prepayment reform, Beijing is leading a comprehensive overhaul of the prepayment system, encompassing hospitals of varying affiliations and tiers. This systematic transformation is rooted in extensive patient group data, with the commencement of actual payments on March 15, 2022. This study aims to evaluate the effectiveness of DRG payment reform by examining how it affects the cost, volume, and utilization of care for patients with neurological disorders.

Patients and Methods

Utilizing the exogenous shock resulting from the implementation of the DRG-based prepayment system, we adopted the Difference-in-Differences (DID) approach to discern changes in outcome variables among DRG payment cases, in comparison to control cases, both before and following the enactment of the DRG policy. The analytical dataset was derived from patients diagnosed with neurological disorders across all hospitals in Beijing that underwent the DRG-based prepayment reform. Strict data inclusion and exclusion criteria, including reasonableness tests, were applied, defining the pre-reform timeframe as March 15th through October 31st, 2021, and the post-reform timeframe as the corresponding period in 2022. The extensive dataset encompassed 53 hospitals and encompassed hundreds of thousands of cases.

Results

The implementation of DRG-based prepayment resulted in a substantial 12.6% decrease in total costs per case and a reduction of 0.96 days in length of stay. Additionally, the reform was correlated with significant reductions in overall in-hospital mortality and readmission rates. Surprisingly, the study unearthed unintended consequences, including a significant reduction in the proportion of inpatient cases classified as surgical patients and the Case Mix Index (CMI), indicating potential strategic adjustments by providers in response to the introduction of DRG payments.

Conclusion

The DRG payment reform demonstrates substantial effects in restraining cost escalation and enhancing quality. Nevertheless, caution must be exercised to mitigate potential issues such as patient selection bias and upcoding.

DRGKB: a knowledgebase of worldwide diagnosis-related groups' practices for comparison, evaluation and knowledge-guided application

As a prospective payment method, diagnosis-related groups (DRGs)'s implementation has varying effects on different regions and adopt different case classification systems. Our goal is to build a structured public online knowledgebase describing the worldwide practice of DRGs, which includes systematic indicators for DRGs' performance assessment. Therefore, we manually collected the qualified literature from PUBMED and constructed DRGKB website. We divided the evaluation indicators into four categories, including (i) medical service quality; (ii) medical service efficiency; (iii) profitability and sustainability; (iv) case grouping ability. Then we carried out descriptive analysis and comprehensive scoring on outcome measurements performance, improvement strategy and specialty performance. At last, the DRGKB finally contains 297 entries. It was found that DRGs generally have a considerable impact on hospital operations, including average length of stay, medical quality and use of medical resources. At the same time, the current DRGs also have many deficiencies, including insufficient reimbursement rates and the ability to classify complex cases. We analyzed these underperforming parts by domain. In conclusion, this research innovatively constructed a knowledgebase to quantify the practice effects of DRGs, analyzed and visualized the development trends and area performance from a comprehensive perspective. This study provides a data-driven research paradigm for following DRGs-related work along with a proposed DRGs evolution model. Availability and implementation: DRGKB is freely available at http://www.sysbio.org.cn/drgkb/. Database URL: http://www.sysbio.org.cn/drgkb/.

Impact of Medical-Pharmaceutical Separation Reform on Hospitalization Expenditure in Tertiary Public Hospitals: Difference-in-Difference Analysis Based on Panel Data from Beijing

Purpose

The medical-pharmaceutical separation (MPS) reform is a healthcare reform that focuses on reducing the proportion of drug expenditure. This study aims to analyze the impact of the MPS reform on hospitalization expenditure and its structure in tertiary public hospitals.

Methods

Using propensity score matching and multi-period difference-in-difference methods to analyze the impact of the MPS reform on hospitalization expenditure and its structure, a difference-in-difference-in-difference model was established to analyze the heterogeneity of whether the tertiary public hospital was a diagnosis-related-group (DRG) payment hospital. Of 22 municipal public hospitals offering tertiary care in Beijing, monthly panel data of 18 hospitals from July 2011 to March 2017, totaling 1242 items, were included in this study.

Results

After the MPS reform, the average drug expenditure, average Western drug expenditure, and average Chinese drug expenditures per hospitalization decreased by 24.5%, 24.6%, and 24.1%, respectively (P < 0.001). The proportions of drug expenditure decreased by 4.5% (P < 0.001), and the proportion of medical consumables expenditure increased significantly by 2.7% (P < 0.001).

Conclusion

The MPS reform may significantly optimize the hospitalization expenditure structure and control irrational increases in expenditure. DRG payment can control the tendency to increase the proportions of medical consumables expenditure after the reform and optimize the effect of the reform. There is a need to strengthen the management of medical consumables in the future, promote the MPS reform and DRG payment linkage, and improve supporting measures to ensure the long-term effect of the reform.

Costs of Air Pollution in California's San Joaquin Valley: A Societal Perspective of the Burden of Asthma on Emergency Departments and Inpatient Care

Introduction

The San Joaquin Valley (SJV) is often recognized as one of the most polluted regions in the US. Periods of pollution exposure are associated with increased health burden related to respiratory inflammation and undermined lung function, which aggravates respiratory diseases such as asthma and leads to symptoms such as coughing, wheezing, or difficulty breathing. Asthma costs US$ 82 billion annually in healthcare costs, missed work and school in the US.

Methods

Employing a societal perspective, a cost of illness design was combined with environmental epidemiological methods to analyze the economic impact of O3, NO2, and PM2.5-related adverse respiratory health outcomes amongst SJV residents who attended the emergency department (ED) or were hospitalized in 2016.

Results

Asthma exacerbations monetized value ranged from US$ 3353 to US$ 5003 per ED visit and for hospital admissions US$ 2584 per inpatient day for adults 65 years and older to US$ 3023 per child. The estimated value to society in healthcare costs, productivity losses, school absences, and opportunity costs from air pollution adverse health outcomes totaled US$ 498,014,124 in ED visits and US$ 223,552,720 in hospital admissions for the SJV population in 2016. The marginal reduction in the background concentrations of pollutants would avert 21,786 ED adverse events and 19,328 hospitalizations from the health burden on the SJV population or US$ 8,024,505 cost savings due to O3, US$ 82,482,683 from NO2 reductions, and US$ 46,214,702 from decreased concentration of PM2.5.

Conclusion

This study provides evidence that air pollution is a negative externality that imposes substantial social, environmental, and healthcare costs on the SJV. Furthermore, the region would avert significant adverse health outcomes realizing economic savings by reducing air pollution and exposures.

Comprehensive evaluation of disease coding quality in gastroenterology and its impact on the diagnosis-related group system: a cross-sectional study

OBJECTIVE

According to the diagnosis-related group (DRG) requirement, issues of diagnosis and procedure coding in the gastroenterology department of our hospital were analyzed and improvement plans were proposed to lay the foundation for effective implementation of DRGs.

METHODS

The title page of case-history of 1600 patients admitted to the Department of Gastroenterology of this hospital from January 1, 2021 to December 31, 2021 was sampled as a data source, and the primary and other diagnostic codes, operation or procedure codes involved in the title page of case-history were categorized and statistically analyzed.

RESULTS

Of the 531 cases treated with gastrointestinal endoscopy in our hospital in 2021, coding errors were identified in 66 cases and unsuccessful DRG enrollment in 35 cases, including 14 cases with incorrect coding of the primary diagnosis (8 cases with unsuccessful DRG enrollment), 37 cases with incorrect coding of the primary operation (23 cases with unsuccessful DRG enrollment), and 8 cases with incorrect coding of both the primary diagnosis and the primary operation (4 cases with unsuccessful DRG enrollment). Analysis of 66 inpatient cases with coding problems showed a total of 167 deficiencies, including 36 deficiencies in major diagnoses, 84 deficiencies in other diagnoses, and 47 deficiencies in surgery or operation coding.

CONCLUSION

The accuracy of coding of disease diagnosis and surgical operation is the basis for the smooth implementation of DRGs. The medical staff of this hospital has poor cognition of DRGs coding and fails to recognize the important role of the title page of case-history quality to DRGs system, and their attention to DRGs and knowledge base of disease classification coding should be improved. In addition, the high incidence of coding errors, especially the omission of disease diagnosis, requires increased training of physicians and nurses on clinical knowledge and requirements for DRGs medical records, thereby improving the quality of medical cases and ensuring the accuracy of DRGs information.

Barriers and Facilitators to Health-Care Provider Payment Reform - A Scoping Literature Review

Background

Changes to provider payment systems are among the most common reforms in health care. They are important levers for policymakers to influence the health system performance. The aim of this study was to identify, systematize, and map the existing literature on the factors that influence health-care provider payment reforms.

Methods

A scoping review was conducted. Literature published in English between 2000 and 2022 was systematically searched in five databases, relevant organizations, and journals. Academic publications and grey literature on health-care provider payment reform and the factors influencing reform were considered. An inductive thematic analysis was applied to map the barriers and facilitators that influence payment reforms.

Results

The study included 51 publications. They were divided into four categories: empirical studies (n=17), literature reviews (n=6), discussion/policy papers (n=18), and technical reports/policy briefs (n=9). Most of the studies were conducted in developed economy countries (n=36). The most frequently reformed payment method was fee-for-service (n=37), and the newly implemented methods included bundled payments (n=16), pay-for-performance (n=15), and diagnosis-related groups (n=11). This study identified 43 sub-themes on barriers to provider payment reforms, which were grouped into eight main themes. It identified 51 sub-themes on facilitators, which were grouped into six themes. Barriers include stakeholder opposition, challenges related to reform design, hurdles in implementation structures, insufficient resources, challenges related to market structures, legal barriers, knowledge and information gaps, and negative publicity. Facilitators include stakeholder involvement, complementary reforms/policies, relevant prior experience, good leadership and management of change, sufficient resources, and external pressure to introduce reform.

Conclusion

The factors that influence health-care payment reforms are often contextual and interrelated, and encompass a variety of perspectives, including those of patients, providers, insurers, and policymakers. When planning reforms, one should anticipate potential barriers and devise appropriate interventions.

Registration

The study was registered with the Open Science Framework.

Does the disclosure of medical insurance information affect patients' willingness to adopt the diagnosis related groups system

Introduction

Medical insurance information disclosure is not only a direct way for the public to understand and master social insurance information and resource use benefits, but also an important way for the public to participate in medical service governance and supervision. Some studies have shown that information disclosure can significantly reduce the risk perception of user groups, strengthen their trust and reduce the negative impact of information asymmetry.

Methods

Based on risk perception and trust perception theories, this paper focuses on the mechanisms influencing patients' attitudes in the process of implementing a Diagnosis Related Groups payment system. Using medical insurance information disclosure from a governance perspective as the research object, the impact of medical insurance information disclosure on patients' willingness to adopt the Diagnosis Related Groups payment system was analyzed by means of a questionnaire survey, Data analysis and hypothesis testing via SPSS while the mechanism of the impact of medical insurance information disclosure on patients' attitudes was explored in depth.

Results

It was found that medical insurance information disclosure had a significant positive effect on patients' trust perceptions and a significant negative effect on patients' risk perceptions. The more comprehensive information patients received, the stronger their trust and the lower their perceived risk.

Discussion

This paper conducts an empirical study from patients' perspective, broadens the scope of research on medical insurance Diagnosis related groups, enriches the application of risk perception and trust perception theories in the medical field, and provides management suggestions for medical institutions in the management of medical insurance information disclosure.

A study of the types and manifestations of physicians' unintended behaviors in the DRG payment system

Introduction

In recent years, China has implemented the Diagnosis Related Groups (DRG) payment system as part of its healthcare insurance reimbursement policy. Numerous studies have focused on the effectiveness of DRG payment system in controlling unreasonable growth in medical expenses. However, there has been no systematic report on the types of unintended behaviors exhibited by doctors under the DRG payment system.

Methods

The study first utilized interrupted time series analysis to analyze medical records and insurance data from eight hospitals. It investigated the data changes in MDC and ADRG groups before and after the implementation of the DRG payment system. Subsequently, a semi-structured interview method was employed to conduct qualitative research on the unintended behaviors of physicians, aiming to gain a more accurate understanding of specific changes in physician behavior after the implementation of the DRG payment system.

Results

This study discovered that doctors engage in unintended behaviors within the framework of the DRG payment system.

Discussion

In the early implementation of the DRG payment system in China, the contradictions between the flawed DRG payment methods and supporting systems and the actual diagnostic and treatment work manifested in the form of unintended doctor behaviors. Most of these unintended behaviors can be considered reasonable feedback from doctors to cope with the existing system flaws. They are conducive to identifying the deficiencies in China's DRG payment system and suggesting directions for improvement.

Impact of Diagnosis-Related-Group (DRG) payment on variation in hospitalization expenditure: evidence from China

BACKGROUND

Diagnosis-Related-Group (DRG) payment is considered a crucial means of addressing the rapid increases of medical cost and variation in cost. This paper analyzes the impact of DRG payment on variation in hospitalization expenditure in China.

METHOD

Patients with chronic obstructive pulmonary disease (COPD), acute myocardial infarction (AMI) and cerebral infarction (CI) in a Chinese City Z were selected. Patients in the fee-for-service (FFS) payment group and the DRG payment group were used as the control group and intervention group, respectively, and propensity-score-matching (PSM) was conducted. Interquartile distance (IQR), standard deviation (SD) and concentration index were used to analyze variation and trends in terms of hospitalization expenditure across the different groups.

RESULTS

After DRG payment reform, the SD of hospitalization expenditure in respect of the COPD, AMI and CI patients in City Z decreased by 11,094, 4,833 and 4,987 CNY, respectively. The concentration indices of hospitalization expenditures for three diseases are all below 0 (statistically significant), with the absolute value tending to increase year by year.

CONCLUSION

DRG payment can be seen to guide medical service providers to provide effective treatment that can improve the consistency of medical care services, bringing the cost of medical care closer to its true clinical value.

Challenges of implementing diagnostic-related groups and healthcare promotion in Iran: A strategic applied research

Background and Aim

Implementing the diagnostic-related groups (DRGs) promotes the efficiency of healthcare. Therefore, the present study aimed to identify the challenges facing implementing the DRGs in Iran.

Methods

The present study is a strategic applied research conducted in two phases. In the first phase, the challenges facing DRGs were extracted through a literature review. Then the collected data is entered into a checklist consisting of five sections including technological, cultural, organizational, strategic, and natural challenges. In the second phase, data were collected by purposive sampling and semistructured interviews with 10 managers of the Medical Services Organization of Tehran, Iran. Data analysis was performed by conventional content analysis using MAXQDA software and descriptive using SPSS software version 19.

Results

The challenges facing the implementing DGRs from the experts' perspective included technological, organizational, nature, strategic, and cultural in order of priority. The three main fundamental challenges were reported; lack of integrating the DGRs with health information system (70%), frequent changes of management (70%), reducing the quality of care following early patient discharge (60%).

Conclusion

The results of the present study showed that the DRG system faced with challenges and healthcare officials should apply policies and guidelines to reform the system before changing the reimbursement system in Iran. By considering the leading countries experiences in the nationalizing the DRG system field, the problems and solutions of the system can be identified and aid in the more successful implementation of these systems.

Diagnosis Related Groups of Patients Admitted from an Urban Academic Medical Center to a Virtual Hybrid Hospital-at-Home Program

Background

The diagnosis related group (DRG) is used as an economic patient classification system based on clinical characteristics, hospital stay, and treatment costs. Mayo Clinic's virtual hybrid hospital-at-home program, advanced care at home (ACH), offers high-acuity home inpatient care for a variety of diagnosis. This study aimed to determine the DRGs admitted to the ACH program at an urban academic center.

Methods

A retrospective study was performed on all patients discharged from the ACH program at Mayo Clinic Florida from July 6, 2020, to February 1, 2022. DRG data were extracted from the Electronic Health Record (EHR). Categorization of DRG was done by systems.

Results

The ACH program discharged 451 patients with DRGs. Categorization of the DRG demonstrated that the most frequent code assigned corresponded to respiratory infections (20.2%), followed by septicemia (12.9%), heart failure (8.9%), renal failure (4.9%), and cellulitis (4.0%).

Conclusion

The ACH program covers a wide range of high-acuity diagnosis across multiple medical specialties at its urban academic medical campus, including respiratory infections, severe sepsis, congestive heart failure, and renal failure, all with major complications or comorbidities. The ACH model of care may be useful in taking care of patients with similar diagnosis at other urban academic medical institutions.

Impacts of a New Episode-Based Payment Scheme on Volume, Expenditures, and Efficiency in Public Hospitals: A Quasi-Experimental Interrupted Time-Series Study in Jinhua, China

Purpose

Based on the diagnosis-related groups payment, China developed an innovative episode-based payment scheme, called "payment method by disease types with point counting", to control health expenditures inflation. This study aimed to investigate the impacts of this new payment method on volume, expenditures, and efficiency in Chinese public hospitals.

Methods

The study sample consisted of 7 tertiary hospitals and 14 secondary hospitals in Jinhua (intervention group) and 4 tertiary hospitals and 14 secondary hospitals in Taizhou (control group). Monthly data points were collected for each sampled hospital from June 2016 to June 2019 using a self-administered questionnaire with impact evaluation indicators. Controlled interrupted time-series analysis was employed to estimate the effect of the new payment method.

Results

The significant slowing trends in inpatient expenditures per visit (tertiary hospitals: β₇=-123.16, p=0.042; secondary hospitals: β₇=-89.24, p=0.021) and out-of-pocket payments (tertiary hospitals: β₇=-4.18, p=0.027; secondary hospitals: β₇=-4.87, p=0.019) were observed after policy intervention. However, outpatient expenditures per visit in tertiary (β₇=1.67, p=0.018) and secondary hospitals (β₇=1.24, p=0.003) rose faster with the new payment method. Additionally, payment reform also caused an increase in the number of inpatient visits (β₇=100.01, p=0.038) and reduced the length of stay (β₇=-0.10, p=0.036) in tertiary hospitals.

Conclusion

The introduction of payment method by disease types with point counting causes the cost containment for inpatient care, whereas the increase in outpatient expenditures. The findings suggest this new payment scheme has the potential for rollout in other areas, but the cost-shifting from the inpatient to outpatient setting should be prevented.

Analysis of the Cost and Case-mix of Post-acute Stroke Patients in China Using Quantile Regression and the Decision-tree Models

Purpose

Post-acute care is fast developing in China, yet a payment system for post-acute care has not been established. As stroke is the leading cause of mortality and disability in China, patients constitute a large share of post-acute-care patients among all hospitalized patients. This study was to identify the cost determinants and establish a case-mix classification of the post-acute care system for stroke patients in China.

Patients and Methods

A total of 5401 post-acute stroke patients in seven hospitals of Jinhua City from January 2018 to December 2020 were selected. Demographic characteristics, medical status, functional measures (eg, the Barthel Index, Mini-Mental State Examination, Gugging Swallowing Screen, Hamilton Depression Scale), and cost data were extracted. Generalized linear model (GLM) and quantile regression (QR) were conducted to determine the predictors of cost, and a case-mix classification model was established using the decision-tree analysis.

Results

The GLM regression revealed that gender, tracheostomy, complication or comorbidity (CC), activities of daily living (ADL), and cognitive impairment were the main variables significantly affecting the hospitalization expenses of post-acute stroke patients. The QR model showed that the gender, tracheostomy and CC factors had a more significant impact on per diem costs on the upper quantiles. In contrast, cognitive impairment had a more substantial effect on the lower quantiles, and ADL significantly impacted the central quantile. Using tracheostomy, CC, and ADL as node variables of the regression tree, 12 classes were generated. The case-mix classification performed reliably and robustly, as measured by the reduction in the variation statistic (RIV=0.46) and class-specific coefficients of variation (CV less than 1.0; range: 0.18–0.81).

Conclusion

QR has strengths in comprehensively identifying cost predictors across cost groups. Tracheostomy, CC, and ADL significantly can predict the expenses of post-acute care for stroke patients. The established case-mix classification system can inform the future payment policy of post-acute care in China.

[The Chinese health system]

Côté santé, la Chine connaît une situation paradoxale, avec des indicateurs dont la courbe de progression est spectaculaire : une espérance de vie passée de 43,7 ans en 1960 à 76,9 ans en 2019 ; des dépenses de santé à hauteur de 5,35 % du produit intérieur brut (PIB) en 2018… Mais un système décrit par de nombreux observateurs comme manquant d’efficacité et des relations excessivement tendues voire violentes [1, 2] entre, d’un côté, le personnel soignant et les médecins et, de l’autre côté, les patients et leur famille. Pour comprendre le système de santé chinois, je m’attacherai dans cette revue à le contextualiser puis je montrerai comment, face à l’incapacité à mettre en place un système fondé sur des modèles existants, ce système de santé est en train de se redessiner en développant un système alternatif de soins.