Capturing patients’ needs in casemix: a systematic literature review on the value of adding functioning information in reimbursement systems

Abstract

BackgroundContemporary casemix systems for health services need to ensure that payment rates adequately account for actual resource consumption based on patients’ needs for services. It has been argued that functioning information, as one important determinant of health service provision and resource use, should be taken into account when developing casemix systems. However, there has to date been little systematic collation of the evidence on the extent to which the addition of functioning information into existing casemix systems adds value to those systems with regard to the predictive power and resource variation explained by the groupings of these systems. Thus, the objective of this research was to examine the value of adding functioning information into casemix systems with respect to the prediction of resource use as measured by costs and length of stay.MethodsA systematic literature review was performed. Peer-reviewed studies, published before May 2014 were retrieved from CINAHL, EconLit, Embase, JSTOR, PubMed and Sociological Abstracts using keywords related to functioning (‘Functioning’, ‘Functional status’, ‘Function*, ‘ICF’, ‘International Classification of Functioning, Disability and Health’, ‘Activities of Daily Living’ or ‘ADL’) and casemix systems (‘Casemix’, ‘case mix’, ‘Diagnosis Related Groups’, ‘Function Related Groups’, ‘Resource Utilization Groups’ or ‘AN-SNAP’). In addition, a hand search of reference lists of included articles was conducted. Information about study aims, design, country, setting, methods, outcome variables, study results, and information regarding the authors’ discussion of results, study limitations and implications was extracted.ResultsTen included studies provided evidence demonstrating that adding functioning information into casemix systems improves predictive ability and fosters homogeneity in casemix groups with regard to costs and length of stay. Collection and integration of functioning information varied across studies. Results suggest that, in particular, DRG casemix systems can be improved in predicting resource use and capturing outcomes for frail elderly or severely functioning-impaired patients.ConclusionFurther exploration of the value of adding functioning information into casemix systems is one promising approach to improve casemix systems ability to adequately capture the differences in patient’s needs for services and to better predict resource use.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1277-x) contains supplementary material, which is available to authorized users.

Comparison between long-acting injectable aripiprazole versus paliperidone palmitate in the treatment of schizophrenia

“…It should be noted, however, that the overlap of items from the PARADISE 24 with measures of diagnostic and symptom severity and quality of life needs to be taken into account to prevent the confounding of estimates in analysis. Our findings supporting the utility of functioning decrements related to 'activities and participation' in costs prediction show that adding functioning information to existing diagnostically defined clusters may improve their predictive ability as has been shown in the general population (Hopfe et al, 2016).…”

“…Nevertheless, our findings that support the predictive utility of functioning correspond with those of a cross-sectional study (n = 7461), whereby 'activities of daily living' was associated with the number of psychotherapy and general practitioner attendances by individuals with 'common mental disorders' (Cooper et al, 2010), but not with those of a cohort study (n = 85), whereby social functioning impairment was not associated with healthcare costs for patients with schizophrenia (Patel et al, 2006). The utility of functioning in predicting costs of care in the general population has also been supported in a recent review (Hopfe et al, 2016). The lack of strong support for the utility of depressive and anxiety symptom severity in predicting costs is in agreement with evidence from numerous studies involving large-scale and national datasets (English et al, 1986;Schumacher et al, 1986;Elphick and Antony, 1996;Cotterill and Thomas, 2004;Macdonald and Elphick, 2011;Prina et al, 2015;Twomey et al, 2015a).…”

“…(DSM-V), whereby it is rated alongside diagnostic severity (Gold, 2014;Lam et al, 2015). The utility of functioning in predicting costs of care in the general population was supported in a recent review (Hopfe et al, 2016), but its utility in predicting costs in mental disorders is unclearthere is mixed evidence from investigations that deployed various domain-specific operationalizations of functioning and uncosted healthcare use outcomes (Patel et al, 2006;Cooper et al, 2010;Twomey et al, 2015aTwomey et al, , 2015b.…”

Effect of patient’s age on the profitability of inpatient cardiac catheterization: a contribution margin analysis of frequently performed procedures over a 5-year period

“…Every DRG is linked to a relative cost weight which reflects the amount of resources requirements an average patient in that DRG is expected to consume. Ideally, relative weights should be in parallel with the hospital costs for each DRG and thus perfectly explain differences in patients’ diagnoses, comorbidities and procedures [37, 38]. The amount of DRG-revenue which exceeds variable costs (= contribution margin) should reflect those cost components which can be allocated to non-procedural patient characteristics as differences in diagnoses, age and comorbidities.…”

Variabilidad de los cuidados de enfermería según APR-GRD y severidad de la enfermedad en una muestra de nueve hospitales belgas

“…Algunos estudios demuestran que la capacidad funcional de los pacientes puede mejorar el sistema GRD y se está considerando su incorporación en la 11ª versión de la clasificación internacional de enfermedades (CIE-11) 6 . Los gestores y líderes de la enfermería deben dirigir esfuerzos para que la información sobre la intensidad y los costes del cuidado se integre en los GRD, pero desde una perspectiva enfermera.…”