Combining DRGs and per diem payments in the private sector: the Equitable Payment Model

Hanning, Brian W T

doi:10.1071/ah050080

Cited by 3 publications

(3 citation statements)

References 1 publication

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“…Private insurance funds use either DRG-based payments or hybrid payment models, which consist of a combination of per diem and DRG based payments, to reimburse care provided to their insured. It is anticipated that in the near future, hybrid models, such as the Equitable Payment Model, will become the standard payment model used by private insurance funds [14].…”

Section: Differences In Casemix Systemsmentioning

confidence: 99%

The risk of upcoding in casemix systems: A comparative study

et al. 2007

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Section: Differences In Casemix Systemsmentioning

confidence: 99%

The risk of upcoding in casemix systems: A comparative study

et al. 2007

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“…Meanwhile, the Episode Clinical Complexity Model was introduced with the emphasis on additional diagnoses ( 93 ). Additionally, DRGs are also widely used in the private sector in Australia ( 94 ). European countries often have their own DRG systems tailored to their specific healthcare contexts.…”

Section: Discussionmentioning

confidence: 99%

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

Ren,

Yang,

et al. 2024

Database

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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/

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“…The per diem system combined with a per case payment including diagnosis groups or department classification has thus emerged in several countries, which adds the motivations to contain costs [21,22]. Furthermore, step-down payment rates tend to replace the flat rates to reduce unnecessary periods of hospitalization [23,24]. Degressive per diem rates are advocated but when and how to diminish the rates remains in doubt [25].…”

Section: Introductionmentioning

confidence: 99%

Cost Sharing and Cost Shifting Mechanisms under a per Diem Payment System in a County of China

Liu

Chen

et al. 2023

IJERPH

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Cost sharing and cost shifting mechanisms are of vital importance in a prospective payment system. This paper employed the difference-in-differences method to estimate the impacts of a per diem system with inverted-U-shape rates on medical costs and the length of stay based on data from a health insurance institution. The supply side cost sharing mechanism worked so that the new payment system significantly reduced medical costs by 17.59 percent while the average length of stay varied little. After further analyzing the mechanism, we found that heterogeneous effects emerged mainly due to the special rates design. The reform decreased the cases that incurred relatively high medical costs and lengths of stay. However, cost shifting existed so that physicians could be motivated to provide unnecessary services to the patients who should have been discharged before the average length of stay. Therefore, payment rates in the per diem system require a sophisticated design to constrain its distortion to medical service provision even though medical expenditures were successfully contained.

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Combining DRGs and per diem payments in the private sector: the Equitable Payment Model

Cited by 3 publications

References 1 publication

The risk of upcoding in casemix systems: A comparative study

The risk of upcoding in casemix systems: A comparative study

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

Cost Sharing and Cost Shifting Mechanisms under a per Diem Payment System in a County of China

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