Influence of DPC on cardiovascular surgery

After a new medical expense system "DPC (Diagnosis Procedure Combination)" had been introduced in 2003, the change in the medical treatment fee was evaluated according to each cardiovascular surgical field. Application of the DPC is limited to hospitalization fee in the general ward by a fixed daily amount The former payment system remains for operation, anesthesia, and some invasive examinations such as cardiac catheterization, therefore, the influence of the DPC introduction on cardiovascular surgery was minimum. A lot of problems are still left, however, for the classification of diagnosis, especially in a congenital heart disease, and the fee setting of intensive care. It is required also to reconsider serious cases, advanced complications and methods of life support. In the field of cardiovacular surgery, the treatment is so risky and so expensive, that more detailed analysis should be necessary by establishment of data base system.     

Effects and measures of the inclusion payment system with disease procedure combination in a respiratory surgical division

There are advantages for hospital managers, payment associations, and politic side with the intrduction of the inclusion payment system with disease procedure combination (DPC). However, what will be the effects on patients and medical personnel? The average length of hospitalization of DPC cases for pulmonary malignant tumor in DPC in hospitals has been shortened. However, hospital stays have been becoming shorter in even in hospitals not subject to DPC, and it appears that there is little effect of DPC on this. It is difficult to confirm the effects of DPC introduction on changes in the quantitative and qualitative use of medical supplies and agents. Less thorough examinations upon admission are one of the most obvious results of DPC. However, preoperative examinations are performed in outpatient departments, and postoperative examinations have not been very much affected. DPC is not only useful as a tool for analyzing hospital management, but also as a tool to analyze the components of medical treatment. We can use DPC to improve medical quality.     

Cost benefit analysis of portable disposable patient-controlled epidural analgesia pump under the diagnosis procedure combination based payment system

BACKGROUND: The aim of this study was to assess how portable disposable patient-controlled epidural analgesia (PCEA) pumps (P group) affect the total costs of postoperative pain management compared with ordinary continuous epidural analgesia pumps without patient-controlled analgesia(C group). METHODS: The hospital income, material costs and costs of drugs for postoperative analgesia were analyzed in 446 surgical patients (C group) between April 2005 and November 2005 and in 417 surgical patients (P group) between April 2006 and November 2006, respectively. RESULTS: Considerable cost savings were achieved when PCEA pumps was used (C group--1300 yen/per patient; P group + 1950 yen/per patient). CONCLUSIONS: PCEA pumps itself work out as designated insured medical materials and additional drugs for postoperative analgesia in the ward is cleared under the diagnosis procedure combination (DPC)-based payment system. Clearance of PCEA pumps under the DPC-based payment system and cost savings of additional drugs for postoperative analgesia in the ward contributed to increases in the profit of the hospital. The DPC-based payment system may offer an economic incentive to introduction of PCEA.     

Effects and measures of the flat payment system based on the diagnosis procedure combination system in pediatric surgery

The current status of the flat payment system based on the diagnosis procedure combination (DPC) system was examined in pediatric surgery. Many important diseases especially in neonatal surgery are not listed for the DPC system due to either the small number of cases or variations in hospital stay or cost In our university hospital, however, the DPC system was applied to 286 (90.8%) of 315 admissions. Total scores for the admissions were slightly higher (103.5%) in the DPC system compared with the fee-for-service system. Scores for inguinal hernia by day surgery and one-night stay were also slightly higher (102.2%) in the DPC system. Future measures for the DPC system include the provision that most preoperative evaluations should be performed in outpatient clinics and further elective surgery at a separate admission is recommended for patients with benign disease or in good condition. In cases of surgery for emergencies or malignancies, too many examinations should be avoided. Postoperative treatment using a clinical path without complications should be performed to achieve shortening of hospital stays and reduced cost. Problems in the current DPC system are complicated and inadequate classification, probably due to the unique and cost-unbeneficial nature of pediatric surgery. To establish a better medical fee system, further efforts to improve the DPC system should be continued.     

Influence of Japan's New Diagnosis Procedure Combination-Based Payment System on the Surgical Sector: Does it Really Shorten the Hospital Stay?

Purpose In 2003, the Diagnosis Procedure Combination (DPC)-based payment system was introduced on a trial basis in 82 major Japanese hospitals. We analyzed the influence of this system on hospital revenue and expenditure, focusing on whether it reduces the length of stay in hospital (LOS), particularly in the surgical sector. Methods We studied 120 patients hospitalized at the University of Tokyo hospital between May and July 2003, including 93 surgical patients who underwent operations for gastric, colon, rectal, hepatic, or mammary carcinoma; arteriosclerosis obliterans; appendicitis; adult hernia inguinalis; or varicose veins, and 27 nonsurgical patients hospitalized for recurrent gastric carcinoma, ileus, appendicitis, or mild acute pancreatitis. We analyzed the changes in profit per day in patients with a reduced LOS using the simulation model. Results Reducing the LOS of the surgical patients resulted in a greater profit; however, there was minimal if any profit increase achieved by reducing the LOS of the medical patients. In fact, when material costs were high, profit decreased. Conclusion The DPC-based payment system does not usually offer an economic incentive to shorten the LOS. Expanding our current system will reduce the LOS only in major hospitals, but it will reduce the national average LOS. Thus, the current DPC-based payment system needs to be improved further.     

Surgeons' fees--What they should be?

Changes in medical technology and economic conditions in Japan require that we reexamine the allocation of medical resources and the structure of surgeon's fees. A new payment system based on Diagnosis Procedure Combination (DPC) and an associated cost accounting system went in to use in 2001. Through quantitative analysis and critique of data gathered by these new systems, it might be possible to establish fair surgeons' fees and to improve the efficiency of the medical care delivery system. For its social responsibility and autonomy, the profession of medicine should take an active leadership role in current health care reforms.     

Influence and provision for comprehensive insurance system--digestive surgery

The diagnostic procedure combination (DPC) was introduced in 82 institutions from April 2003. DPC is similar to the diagnosis-related group and prospective payment system, which is widely used in the USA. The payment of DPC is calculated by multiplying the cost/day in each DPC, hospital stay in days, and index of each hospital, which is determined by several variables including the mean hospital stay in the previous year. After the introduction of DPC, clinical and diagnostic examinations, and cancer chemotherapy were shifted from the inpatient to outpatient setting in our institution, as well as in most of the other institutions reported by the Ministry of Health, Labor and Welfare. Because of the examinations in the outpatient clinic, the preoperative hospital stay was shortened. To validate the safety and effectiveness of cancer chemotherapy in the outpatient clinic, a central system was established in our institution by unifying the protocols and limiting the maximum administered doses by computer. After introduction of DPC, the average hospital stay was shortened in most institutions including ours. In spite of the satisfaction of the patients surveyed, the benefits of DPC should be confirmed based on the final outcome in terms of clinical therapeutic results.     

Effect of DPC based payment and its future

Since 2003, the DPC based bundle type payment scheme has been applied for the acute care hospitals, including the special function hospitals. The DPC scientific committee under the Central Social Insurance Medical Council has examined the change in hospital services after the introduction of DPC based payment. It has been observed the reduction of ALOS, resource uses such as laboratory test radiological examination, drugs and supplies. The under treatment due to strong incentive for cost containment has not been observed up to now.     

Age, resource consumption, and outcome for surgical patients at an academic medical center

Many changes are under way in the payment for physician and hospital care of the surgical patient. Relatively little data have been analyzed on resource consumption for hospitalized surgical patients. The purpose of this study was to characterize hospital resource consumption and outcome by age for surgical patients. All surgical admissions at a large academic medical center from Jan. 1, 1985, through March 31, 1986, were analyzed by means of the diagnostic related group (DRG) format. Total costs (exclusive of physician fees) for the 7341 surgical patients studied were $58,206,815. Mean cost per patient, length of stay, percent of outliers, and mortality increased with age. DRG case-mix index and the number of procedures per patient peaked at age 69 and then decreased. Emergency admission was high for the young (i.e., aged 18 to 24 years) and for very elderly patients (i.e., aged over 75 years). Blood transfusions increased steadily as the age of the patient increased; use of surgical intensive care units increased until age 64 years, then plateaued. This study demonstrated a number of trends in surgical patient age and use of resources. Under prospective payment systems (i.e., DRG reimbursement) financial risk increased with the age of the patient. Length of hospital stay and mortality increased with age; however, DRG case-mix index and the number of procedures per patient peaked at age 69, which suggests that elderly surgical patients (i.e., those above 70 years of age) may be more severely ill on average than younger patients.     

Ausreißerfälle in den operativen Disziplinen

Postoperative complications will always occur and the negative impact puts strain on patients, relatives and the attending physicians. The conversion to a remuneration system based on flat rates (diagnosis-related groups) presents additional economic problems for hospitals in some resource-intensive treatments. This particularly pertains to extremely cost-intensive cases in which costs succeed revenue by the factor of 2 and are often surgical procedures. Here the economic risk increases with the number of interventions performed. Despite improvements in the remuneration system this problem persists. An improved payment for these treatments is desirable. To achieve this it is necessary to systematically analyze the extremely cost-intensive cases by experts of different medical disciplines to create a data basis for a proposal of a cost-covering payment.     

Original Article: The impacts of DRG payment system on financial balance of multiple trauma: Experiences of three trauma centers in Taiwan

IntroductionThere are concerns regarding the adequacy of applying the diagnosis-related groups (DRG) payment system for multiple traumas (i.e., major diagnostic category 24, MDC-24) patients in Taiwan. Therefore, this study used a multi-center dataset to assess the influence of the DRG payment system on the cost and outcome of multiple trauma care.Materials and MethodsWe collected data of all multiple trauma patients from the Trauma Registry of three hospitals from 2014 – 2017. Next, we selected patients who met the criteria of MDC-24 and calculated the corresponding DRG payment. Subsequently, we combined the clinical care information with health insurance information to analyze the problems of applying the DRG payment system to multiple trauma care.ResultsOverall, of 465 cases, 367 met the criteria of MDC-24, and the mean injury severity score (ISS) was high (average 20.1). The total deficit of the polytrauma DRG cases amounted to 131,445 USD, and the average deficit in each case was 397 USD. In the multivariable analysis, higher revised trauma score and specific lower abbreviated Injury Scale (AIS) scores in certain body regions resulted in profits, while increased length of stay in intensive care units, longer operative time, and higher AIS score in the thorax were significantly correlated with deficits in medical costs.ConclusionOur study revealed that the current DRG payment system results in financial losses for hospitals. Further, the payment grouping of MDC-24 should consider adding more disease severity factors to reduce the financial constraints faced by trauma centers.     

Medicare physician payment rules for 2011: a primer for the neurointerventionalist

Physicians generally have been affected by significant changes in the patterns of medical practice evolving over the past several decades. The Patient Protection and Affordable Care Act of 2010, also called ACA for short, impacts physician professional practice dramatically. Physicians are paid in the USA for their personal services. The payment system is highly variable in the private insurance market; however, governmental systems have a formula based payment, mostly based on the Medicare payment system. Physician services are billed under part B. The Neurointerventional practice is typically performed in a hospital setting. The VA system is a frequently cited successful implementation of a government supported health care program. Availability of neurointerventional services at many VA medical centers is limited. Since the inception of the Medicare program in 1965, several methods have been used to determine the amounts paid to physicians for each covered service. Initially, the payment systems compensated physicians on the basis of their charges. In 1975, just over 10 years after the inception of the Medicare program, payments changed so as not to exceed the increase in medical economic index. The involvement of medical economic index failed to curb increases in costs, leading to the determination of a yearly change in fees by legislation from 1984 to 1991. In 1992, the fee schedule essentially replaced the prior payment system that was based on the physician's charges, which also failed to curb the growth in spending. Thus, in 1998, the sustainable growth rate system was introduced. In 2009, multiple unsuccessful attempts were made by Congress to repeal the formula. The mechanism of the sustainable growth rate includes three components that are incorporated into a statutory formula: expenditure targets, growth rate period and annual adjustments of payment rates for physician services.     

Stimulation of medical personnel work in operating rooms]

Preliminary results of experimental trial on stimulation of medical staff's labour in the operation unit, held in medical institutions of Chelyabinsk, has been analysed. As a basis for calculation of the payments for the work, the labour expenditures of each member of surgical team (surgeon, assistant, anesthesiologist, surgical nurse, anesthesist, litter bearer nurse) and the cost of 1 hour work were assessed, the degree of the difficulty of each operation, as well as the total cost of the procedure was determined. Registration of the work of all members of the surgical team and its payment, according to the quantity and the quality of the performed operations, demonstrates the stage of transition to the system of payment for the labour, i.e.--for the concrete work, done by somebody of the staff (for the treatment of some patient, etc.). The evaluation of the work according to the number of treated patients (operations being done) and to the quality of the treatment provides the conditions for personal financial incentive of surgical staff to intensification of their work and contributes to the achievements of favourable final results and in the same time--it provides decrease of the terms for patients' stay in the hospital, saving money and material resources.     

Approaches to assessing the benefits and harms of medical devices for application in surgery

Background

The surgical community and the medical device industry enjoy a fruitful cooperation for the benefit of patients, but during the last years several high-risk products have led to problems and scandals, thus highlighting the need for reforms in European CE marking requirements. In October 2013, the European Parliament voted on a draft regulation on medical devices that intends to replace the current directives in 2014.

Purpose

This article offers guidance to surgeons on how to select and assess medical devices for clinical use. Examples include artificial sphincters, surgical meshes, as well as single-incision and robot-assisted surgery. It is important that surgeons have a basic understanding of the requirements for CE marking of new medical devices. Because device performance rather than effectiveness is required for European market entry, surgeons (and their patients) are often left with the burden of using potentially harmful devices. In addition, potential problems concerning the safety or effectiveness of approved devices are concealed by the lack of data transparency. Because regulatory reforms were blocked at the European level, many member states will now seek other ways of restricting the use of medical devices with unknown effectiveness. One interesting model in this regard is to link the reimbursement of new medical devices to the conduct of clinical trials.

Conclusions

Surgeons should develop a structured multidisciplinary approach to innovation management in their hospitals before using a new high-risk device. The key question is how to strike the right balance between innovation and safety.     

Utilization and outcome in the medical patient referred to surgery

The objective of this study was to test the hypothesis that hospitalized patients referred to a general surgical service from a medical service for a surgical procedure would have higher hospital costs and longer lengths of stay per diagnosis-related group (DRG) than patients admitted directly to the general surgical service. Hospital costs by DRG, exclusive of physician's fees, were analyzed for all adult general surgical admissions treated at our hospital from January 1, 1985 to March 31, 1986 (3,028 patients) to yield a population of patients in those DRGs with patients referred to general surgery from medicine (1,495 patients). Patients within each DRG were then disaggregated by either direct admission to general surgery (1,412 patients) or referral to the general surgical service from the medical service (83 patients). Mean cost per patient was 146.5 percent higher for referral patients than for direct admission patients, as was the total length of stay. Mortality was higher for referral patients than for direct admission patients. Factors analyzed which contributed to this greater resource utilization and higher mortality were (1) a greater severity of illness, (2) higher diagnostic costs, and (3) delays in diagnosis or treatment. The DRG payment for referral patients also produced a substantial deficit for the hospital, whereas direct admission patients produced a profit of +1,105,596. This data suggests that direct admission to the surgical service of patients likely to need surgery might lower their hospital costs and improve the quality of their care.     

Assessment of medical resource utilization for Taiwanese children hospitalized for intracranial injuries

Background

Compared to adults, children and adolescents are at greater risk for traumatic brain injury (TBI), with increased severity and prolonged recovery when compared to adults. It is a challenge to provide care for those children who are at risk for complications of TBI under health care resource constraints.

Aim

To investigate hospitalization among children with intracranial injuries in terms of incidence and factors related to length of stay (LOS) and medical cost.

Methods

Data from the National Health Insurance Research Database from 2007–2009 were used. In total 8632 children aged <=18 years with acute traumatic intracranial injuries caused by accidents were discharged from hospitals in Taiwan. The associations between patient and hospital covariates (e.g., age, gender, accreditation level of hospital, surgical intervention, and number of comorbid conditions) and log-transferred hospitalization cost and length of stay (LOS) were examined with multivariable regression analysis and mediation analyses.

Results

The incidence rate of hospitalization for acute intracranial injury was 63.3/100,000 per year. Motor vehicle crashes and falls accounted for 63.5% and 23.8% of intracranial injuries, respectively. The mean LOS for children was 5.0 days (median, 3 days), incurring a mean direct medical cost of $US 916.70 (median, $356.2). Boy sustained more injury (64.1%) and greater medicals cost ($965) occurred in boys. Patients with subarachnoid subdural and extradural haemorrhage tended to have a longer LOS and incur greater medical costs. Surgical intervention and type of healthcare institution were also significant predictors for medical costs. Additionally, LOS was the dominant mediator for the relationship between predictor and medical cost.

Conclusions

Acute intracranial injuries among children incur a substantial health care burden. Therefore, health authorities need to optimally allocate medical resources in care.     

Zuzahlungspauschale bei minimal-invasiven Operationen

Objective

Increasing costs of the healthcare system might decrease the spectrum of insurance financed medical treatment in the future. Therefore we evaluated whether patients are prepared to pay partial costs of their own, especially for minimally invasive surgery.

Methodics

Between 1st July 2007 and 1st July 2008 patients were asked in a prospective trial preoperatively and postoperatively whether they would be prepared to pay an additional invoice of 200?EUR for a minimally invasive operation. Payment was reasoned by the hypothesis that insurance companies will reduce the DRG payment while costs are rising.

Results

A total of 750 patients, men:women=279 (37.2%):471 (62.8%) undergoing elective minimally invasive operations were included in the trial. For the majority of patients (m=266:13; w=448:23) it was very important to be operated on in a center for minimally invasive surgery. Preoperatively and postoperatively the majority of patients voted for individual payment of 200?EUR to make minimally invasive surgery possible (84.4 versus 84.1%, respectively, p=0.79). Although 80.4% (411/511) of patients with national health insurance voted for payment, voting of patients with private insurance was significantly increased to 92.9% (222/239) (p<0.001). Voting for individual payment increased with a rising level of education (p=0.017), job position and income (p<0.001). Furthermore, it was significantly increased in married compared to single patients (86.5% versus 78.4%, respectively, p=0.038).

Conclusion

Before the operations 84.4% of patients voted for additional individual payment for minimally invasive operations but this was dependent on the socio-economic status.     

Patterns of Ninety-Day Readmissions Following Total Joint Replacement in a Bundled Payment Initiative

Background

Alternative payment models aim to improve quality and decrease costs associated with total joint replacement. Postoperative readmissions within 90 days are of interest to clinicians and administrators as there is no additional reimbursement beyond the episode bundled payment target price. The aim of this study is to improve the understanding of the patterns of readmission which would better guide perioperative patient management affecting readmissions. We hypothesize that readmissions have different timing, location, and patient health profile patterns based on whether the readmission is related to a medical or surgical diagnosis.

Arterial protocol including prophylactic distal perfusion catheter decreases limb ischemia complications in patients undergoing extracorporeal membrane oxygenation

Objective

Venoarterial extracorporeal membrane oxygenation (ECMO) is a salvage therapy in patients with severe cardiopulmonary failure. Owing to the large size of the cannulas inserted via the femoral vessels (≤24-F) required for adequate oxygenation, this procedure could result in significant limb ischemic complications (10%-70%). This study evaluates the results of a distal limb perfusion arterial protocol designed to reduce associated complications.

Simple calculator to estimate the medical cost of diabetes in sub-Saharan Africa

AIM: To design a medical cost calculator and show that diabetes care is beyond reach of the majority particularly patients with complications.METHODS: Out-of-pocket expenditures of patients for medical treatment of type-2 diabetes were estimated based on price data collected in Benin, Burkina Faso, Guinea and Mali. A detailed protocol for realistic medical care of diabetes and its complications in the African context was defined. Care components were based on existing guidelines, published data and clinical experience. Prices were obtained in public and private health facilities. The cost calculator used Excel. The cost for basic management of uncomplicated diabetes was calculated per person and per year. Incremental costs were also computed per annum for chronic complications and per episode for acute complications.RESULTS: Wide variations of estimated care costs were observed among countries and between the public and private healthcare system. The minimum estimated cost for the treatment of uncomplicated diabetes (in the public sector) would amount to 21%-34% of the country’s gross national income per capita, 26%-47% in the presence of retinopathy, and above 70% for nephropathy, the most expensive complication.CONCLUSION: The study provided objective evidence for the exorbitant medical cost of diabetes considering that no medical insurance is available in the study countries. Although the calculator only estimates the cost of inaction, it is innovative and of interest for several stakeholders.