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G.G. Hofmann · Präsident des Berufsverbandes

Deutscher Internisten (BDI) e.V., München

Vorwort zu den folgenden Artikelnüber australischeDRGs

Perspectives on casemix-based funding in Victoria (1995),Casemix Funding (1999)

Im Folgenden werden hier zwei austra-lische Artikel zum Thema DRGs undCasemix im Originaltext publiziert. Dererste Artikel aus dem Jahre 1995 gibteinen Überblick über die Erfahrungenaus fünf unterschiedlichen Sichten einJahr nach Einführung der diagnosebe-zogenen Fallpauschalen und der daraufbezogenen Fallmischung.

Der zweite Artikel aus dem Jahre1999 berücksichtigt dann die in den vierJahren gewonnenen Einsichten. Beimderzeitigen Stand der Entwicklung vondiagnosebezogenen Fallpauschalen inDeutschland auf der Basis der australi-schen DRGs scheint die Kenntnis derErfahrungen unserer australischen Kol-legen hilfreich.

ly this credibility is stretched to its lim-it. Coding audits reveal the accuracy ofdiagnosis coding, but there is no audit ofthe clinical validity of the diagnoses. Im-portantly, „DRG optimisation“ has sig-nificantly improved clinical documenta-tion. Individual units now also examinetheir DRG „profit and loss“ status whenbudgetary constraints are mooted. Clin-ical practice is examined if discrepan-cies in length of stay or cost are foundcompared with other units or institu-tions. This greater understanding of thecosts of hospital care and the uses ofcasemix data and information technol-ogy has been instructive. However, it hashighlighted the deficiencies in hospitalcosting systems and in the AN-DRGclassification system.

„Greater understanding of thecosts of hospital care and the

uses of casemix data and infor-mation technology has been

instructive.“

When initial recognition of achieve-ments in increasing throughput and re-ducing waiting lists was met with chan-ges in budgetary programs (especiallycapping the throughput pool), disen-chantment and uncertainty about thefuture set in. Morale in the Victorianpublic hospital system is now low, andthere has been reticence to publicly crit-icise for fear of retribution.

From optimism to disenchantment

The introduction of output-based fund-ing for acute inpatient services in Victo-rian public hospitals was met with cau-tions optimism and led to a dramatic in-crease in inpatients treated. This reflect-ed both a real increase in the number ofinpatients, as well as a reclassification ofshortstay or ambulatory patients to in-patient status.

Procedural specialties came underpressure to reduce waiting lists and gen-erate more „income“ for their hospitals.This pressure occasionally compro-mised training, especially for juniormedical staff whose lack of expertise po-tentially limited throughput.

Casemix funding has focused atten-tion on better discharge planning andgreater involvement of community ser-vices, although this is far from optimal.Better discharge planning led to bettercoordination and more timely diagnos-tic and therapeutic procedures.With thethroughput funding pool it was easier toadmit patients who needed to be in hos-pital because they generated „income“.However, the capping of this pool andthe subsequent bed closures to meetbudgetary targets have made it difficultto admit patients.

Individual clinicians now meet withmedical record administrators and fi-nance managers to discuss theirthroughput, average length of stay, andother casemix matters. Such meetingslead to DRG „optimisation“ to ensurethe greatest “income” while remainingclinically credible, although occasional-

P.A. Phillips · J.T. Kennedy · G.R. Segal · M.R. Jones · R.G. Larkins

Perspectives on casemix-based funding in VictoriaFive Victorian doctors describe briefly how the first year of casemix-based fundingaffected their practice of medicine

Aus: The Medical Journal of Australia,Vol 162,

19 June 1995

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An important aspect of outputfunding should be maintaining andmonitoring quality. Data on quality ofcare have not been forthcoming, and itis now impossible to distinguish the im-pacts of casemix and changing fundingprograms on quality of care.

(P.A. Phillips, DPhil, FRACP, Con-sultant Physician and Associate Profes-sor of Medicine. Department of Medici-ne, University of Melbourne,Austin andRepatriation Medical Centre, Heidel-berg,VIC 3094).

Good for governments

A real problem with casemix-based fund-ing, from a surgeon’s viewpoint, is thelack of adequate and detailed costingstudies, despite the fact that the AN-DRGclassification is in its second version.Thishas led to inappropriate over- and under-funding. Moreover, not enough DRGs,particularly for surgical patients, are cor-rected for complications, and those forcancer are under-funded. In an effort tobolster funds and counter Government-imposed deficits in non-casemix fund-ing,administrators have given preferenceto low cost, high revenue DRGs (e.g.,same-day admissions).

There are at present no DRGs forambulatory care and hospitals, in costshifting,have privatised outpatient facil-ities, restricted access to them. Patientssuffer because of inadequate follow-up,and trainees – interns, residents and reg-istrars – do not gain experience in am-bulatory conditions and are not able tofollow patients’ postoperative progress.

On the positive side, there was anincrease in productivity of about 20% insome hospitals. Extra throughput funds,designed to reward hospitals able totreat mare patients efficiently, weremade available and, with theatre timeand beds available, surgeons were ableto reduce waiting lists.

However, in the first quarter of1994–95 administrators,attempting to re-duce budget deficits, reached their WIEStargets and then encouraged treatment ofproductive DRGs (patients requiringlow-cost surgical procedures). This hasmeant that, of a pool of $ 42 million forthe year, $ 29 million has been claimedand the pool has „dried up“. In response,administrators have now closed beds,waiting list have grown longer and in-centive is gone.

This situation has also compro-mised undergraduate and postgraduatetraining because of a lack of patientnumbers. Emergency room access is re-stricted because of a lack of beds andpreference is again being given to daysurgery to keep up WIES targets, butmany patients cannot be treated as daypatients.

The casemix system relies heavilyon the efforts of doctors and nurses, andtheir participation is vital for the accu-rate documentation of each patient’shistory and diagnoses to ensure appro-priate and correct diagnosis-relatedgrouping. Correct archiving of historiesis important to allow co-morbidities tobe recorded and the system later cor-rected for appropriate cost-group allo-cation.

„Not enough DRGs, particularlyfor surgical Patients, are

corrected for complications.“

Length of stay is in inappropriatebenchmark for DRGs and affects conti-nuity of treatment. Ideally, surgeonsshould be able to follow patients fromadmission, through operation and hos-pital stay and into outpatients. It is alsoimportant for the trainee to experiencethis continuity.Because of length-of-stayconstraints, however, hospitals are nowinterfering with this sequence.

Overall, casemix funding has creat-ed a situation which is good for govern-ments; they pass the responsibility on tohospitals and hospital administrators,who are forced to close beds and cut ser-vices. Doctors and nurses are left to bearthe brunt of the complaints of patientsplaced on long waiting lists or „short-shrifted“ when they are admitted. Therehas been a sharp increase in complaintsby patients about short hospital admis-sions and, sometimes, inadequate dis-charge planning and lack of outpatientcare.

One advantage of casemix fundingis that it has made everyone more awareof hospital costs and made some hospi-tal procedures more efficient withoutcompromising patient care.

(J.T. Kennedy, FRACS, ConsultantSurgeon and Director, Ear Nose andThroat, Head and Neck Surgery St. Vin-cent’s Hospital, 41 Fitzroy Parade, Mel-bourne,VIC 3002).

Some patients are not welcome

A year ago, on asking an average citygeneral practitioner to explain what heor she knew about casemix, a commonreaction would have been a shrug of theshoulders. City GPs were indifferent tocasemix. It was something for specialistsand rural GPs to worry about.After all, itwas only going to be a concern for doc-tors involved with public hospitals.

A year on and attitudes have chan-ged radically.GPs might not have to codeor know which DRG classification theirpatients fall into, but they have learntwhich patients are not welcome in thesystem.

Hospital admission bias has be-come a fact of life. Every day elderly pa-tients lie on beds in casualty for hours.GPs are told by the „admitting officer“how „tight“ the bed situation is and thattheir elderly patients with pneumoniawill respond just as well to antibiotictherapy at home. Patients who are old,or patients with complicated medical orpsychiatric problems, are not welcome.

Increased throughput? This mightbe happening, but not in any real andmeaningful way. Most GPs are aware ofpatients on waiting lists for inordinateand inappropriate times. They are alsoaware of the other side of the coin – ear-ly and uncoordinated discharge. Beforecasemix, obstetric patients were dis-charged early. Now it is even earlier!

Not everything is negative. A yearon and GPs are learning fast and are cer-tainly very aware of casemix. If it is in-troduced into the private health sector,then they will need to become evenmore aware.

(G.R. Segal, MB BS, General Practi-tioner.[Metropolitan General Practition-er], Chadstone Medical Centre, 21–23Chadstone Road, Chadstune,VIC 3148).

Budget cuts muddied the waters

The introduction of casemix funding ar-rangements in Victoria had the supportof the healthcare field. Particularly forhospitals that had been very efficient inprevious years,but were being disadvan-taged by across-the-board funding cuts,casemix-based funding was seen to bemuch more equitable than historicallybased budgets. Clinicians generally wereinterested in the concept, keen to see it

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done properly, and concerned to ensurethat they played their part in achievingthe hospital’s goals.

Considerable education, particular-ly of resident medical staff,was required,together with upgrading of medicalrecords resources, to enable hospitals toprovide accurate and timely data.

The new arrangements did workinitially, and the concept of a through-put pool rewarding additional produc-tivity made a substantial contribution toreducing urgent cases on elective wait-ing lists. It enabled hospitals to be en-trepreneurial in the way that they ap-proached waiting-list problems andmany hospitals had marked success.

Unfortunately, the introduction ofmajor health budget cuts at the sametime as casemix funding muddied thewaters. Despite attempts by the Victori-an Department of Health and Commu-nity Services to keep these two issuesseparate, they have become inextricablyentwined. Furthermore, when it becameobvious that there were some major de-fects within certain categories of DRGs,the mechanisms for addressing thesehave been unduly protracted.

Although the available money forcapital expenditure was distributed ac-cording to weighted separations, theamount has been inadequate and mech-anisms need to be developed to buildadequate capital funding into the formu-la.

(M.R. (Taffy) Jones, MB BS, FRAC-MA, Director of Medical Services [Clin-ical Services Administrator]. AustinHospital, Heidelberg,VIC 3084).

No final verdict yet

Although the medical fraternity wasaware of the chequered history of case-mix funding in the United States, its in-troduction in Victoria was generally wel-comed because of the haphazard and ar-bitrary nature of the historical fundingwhich preceded it. Hospitals had usual-ly handled budget difficulties by at-tempting to reduce activity and shiftcosts to the Commonwealth. The first 15months of operation of casemix general-ly justified the positive response to itsintroduction, although a number ofproblems emerged.

The marked reduction (effectiveabolition) of the „throughput bonuspool“ in late 1994 left most doctors, ad-ministrators and patients totally disen-chanted with the system. The efficienthospitals that had geared up activity tomeet demand in the expectation of pay-ment for this increased activity found,well into the financial year, that little ad-ditional money was available.These hos-pitals had to suddenly revert to the oldmethods of reducing throughput belowdemand by closing beds and operatingtheaters to. meet budgets.

These problems, of course, relatemore to massive health budget cuts thanto the casemix system, but the incentivesof the system are lost when targets areset below demand and capacity.

„The system handles elderlypatients with multiple medical

and social problems poorly.“

Other problems have emerged. Thesystem is much more attuned tostraightforward procedural activitiesand handles elderly patients with multi-ple medical and social problems poorly.

As these patients occupy a large and in-creasing proportion of beds inmetropolitan hospitals, the system re-quires considerable refinement to dealwith these patients.Additionally, restric-tion of casemix in inpatients providesperverse incentives to admit patients.Comparable systems for funding outpa-tient services must be devised urgently.Psychiatric, aged care and rehabilitationservices must also be addressed.

Another major priority is the devel-opment of a robust system for fundingeducational and research activities ofmajor hospitals. The arbitrary systemused in Victoria requires refinement, butis preferred to the counterproductiveprocess of minute dissection of staff ac-tivities and hospital costs on a moment-to-moment basis, with destructive ef-fects on teaching and research,which arefrequently interwoven with service ac-tivities.

The final verdict on casemix fund-ing in Victoria has not been reached.Major cuts in the health budget have socomplicated and dominated the picturethat the system has not had a chance towork. Refinements are required. Withthese refinements and sufficient fundingto allow a realistic „bonus pool“ itpromises more than historical funding,and the cumbersome „funder-provider“split systems.

(R.G. Larkins, MD, FRACP, PhD,Professor of Medicine. University ofMelbourne, Department of Medicine,Royal Melbourne Hospital,VIC 3050).