An examination of winners and losers under Medicareʼs prospective payment system

Challenges and Adverse Outcomes of Implementing Reimbursement Mechanisms Based on the Diagnosis-Related Group Classification System: A systematic review

“…[25][26][27][28]31,32,37,42,47 Personnel-related challenges were also reported by eight studies (22%); of these, one of the most important was a lack of familiarity among physicians with the DRG classification system and misconceptions regarding the objectives of the mechanism. 25,29,30,33,34,41,42,48,49 No leadership challenges were reported by any of the studies.…”

“…[15][16][17][18][19][20][21]23,24,[27][28][29]31,34,35,[37][38][39][40][41][42][43][44][45][46]48,49 Most studies (n = 31; 86.1%) were set in the USA. [15][16][17][18][19][20][21][22][23][24][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43]…”

“…[14][15][16][17]19,[21][22][23][24][26][27][28]31,32,[34][35][36][37][38][39][40][42][43][44][45][46][47][48][49] In addition, there were three qualitative (8.3%) and four mixed-method (11.1%) studies. 18,20,25,29,30,33,41 In terms of quality assessment, qualitative, quantitative and mixedmethod studies received scores of >70%, >80% and >85%, respectively; however, quantitative studies were generally higher in quality compared to qualitative and mixed-method studies [ Table 1]. Table 2 summarises the studies which identified challenges in the implementation of DRG-based reimbursement mechanisms.…”

“…Overall, 15 studies (41.7%) reported managerial challenges. 25,30,32,[34][35][36][38][39][40][42][43][44][45][46][47] Of these, 12 (80%) indicated that DRG-based reimbursement mechanisms were not suitable for certain services due to the high cost involved and the likelihood of financial loss, including skin care, trauma, fibrocystic disease, heart surgery, rare diseases, urology disorders, mental disorders, intensive care and the care of elderly and paediatric patients. [34][35][36][38][39][40][42][43][44][45][46][47] The remaining three studies (20%) reported delayed reimbursement of hospital fees, increased expenses in educational hospitals (especially at baseline and in rural areas), poor medical recordkeeping and a lack of coding rules and standards.…”

“…[34][35][36][38][39][40][42][43][44][45][46][47] The remaining three studies (20%) reported delayed reimbursement of hospital fees, increased expenses in educational hospitals (especially at baseline and in rural areas), poor medical recordkeeping and a lack of coding rules and standards. 25,30,32 Two studies (5.6%) examined organisation environment challenges, including poor compliance with guidelines, the misfiling and potential loss of patients records and physicians being pressured to discharge patients prematurely. 25,33 Technical challenges were reported by nine studies (25%), particularly data coding and misclassification issues and DRG creeping (i.e.…”