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UNU-CBG: New Casemix System Tool ToEnhance Quality and Efficiency in Developing
Countries
International Institute For GlobalHealth (UNU-IIGH)
Professor Dr Syed Mohamed Aljunid
MD (UKM) MSc (Public Health)( Singapore) PhD (London); DLSHTM(London); FAMM
Professor of Health Economics & Consultant Public HealthMedicine
Senior Research Fellow
United Nations University-International Institute ForGlobal Health
Kuala Lumpur
a enges n oc a eaInsurance Schemes in Developing
Countries! Low coverage (breath and depth)
! Inadequate resources especially for social insurance
! Unaffordable Premium especially for poor and near poor
! Limited Benefit package
! High level of inefficiency
! High administrative cost! Moral Hazards of Consumers and Providers
! Delay in claim processing
! Poor Provider Payment Mechanisms! Use of retrospective payment methods (e.g. FFS/Itemised bill)
! Services Of Poor Quality! Lack of proper review and monitoring
! Low patient satisfaction
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! Reduce Administrative Cost! Should not be more than 10% of operating cost
! Control of moral hazards
Effective and efficient ways of controlling moral hazards
! Consumers: Co-payment
!
Providers: Utilisation Review, Medical Audit
!
Use efficient provider payment mechanism
! Regular Review of Benefit Package!
Include new services
! Exclude non-essential services
! Work with the Stakeholders
! Increase acceptance of consumers & providers
Whatis Casemix System ?
Casemix System is a classification
ofpatient treatment episodes
designed to create classes which
are relatively homogenousinrespect of the resources usedand
which contain patients with
similar clinical characteristics.
(George Palmer, Beth Reid,2000)
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What is Casemix?
" Refers to the Type and Range of Cases
treated in hospitals and clinics
"
Defines Hospital Final Output, Classified intoPredetermined Categories
" Provides Information on Resource Use andQuality
" Describes patients characteristics including
outcome of care
" Can be used as standards for comparison
Benefits of Using CasemixSystem
!
Improve Efficiency of Health Care Services health
"Identify unnecessary services
"Reduce wastages and Cost Savings
!
Improve Quality of Care
"Enhance Quality Assurance Programme
"Facilitate Benchmarking Exercise
"Improve Patient Satisfaction
! Improve Health Management Information System
"Provide high quality data on patient care
"Provide information for review and monitoring
"Promote Better Decision Making
"Encourage Evidence-Based Practice
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Case-mix System Reimbursement:Advantages
!
Risk shared between funders and providers
!
Remove incentive to over treat patients#Payment based on package
! Fair remuneration to providers
#Payment based on severity level
! Payment based on productivity
#Payment based on intensity of care not just volumes
!
Enhance Quality Assurance Programme
! Transparency and objective in computation of tariff
Case-mix SystemReimbursement: Advantages
! Faster and easier to Process Payment
! Easier to verify claims
! Tariff can be easily updated
!Annual updating of Hospital Base-Rates
!Annual/Bi-Annual updating of Cost-weights
! Fraudulence Claims can be detected
and avoided
!Assignment of severity level by grouper
! Random checking can be easily done
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Casemix System in Developing Countries:The Obstacles
! Limited Access to Casemix Tool Casemix Groupers are mainly proprietary owned
Difficult to be customised for local need
Need access to source code for customisation
! Lack of Financial Resources! Case-Mix Consultants are expensive
! Commercial Case-Mix Softwares are costly
! Slow acceptance by Practitioners
! No capacity to refine or expand case-Mix groupings
! No groupings for chronic diseases/subacute cases
! Tariff not updated
! No continuous refinement of DRGs groupings not refined
What Do We Do inUNU-IIGH?......
! Build human resource capacity inCasemix
! Series of Training Workshops
!
E-learning Programme! Support local development of casemix system
! Provide access to Casemix Tool! Casemix Grouper
! Digital Coding Tool
! Clinical Costing Software
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Implementation of Case-Mix System inDeveloping Countries
Disease &
Procedure Codes
Financial
Data
CCM
DRG-
Grouper
Cost-Weights
CUSTOMISED
DRG
GROUPER
Hospital Base
Rate
NATIONAL
HOSPITAL
TARIFF
Case-Mix Index
Softwares in Case-Mix System
! Digital Coding Tool
! Data Tool- Assist to enhance productivity of Coders
! UNU-Code Assist- Assist in Verifications of Casemix codingand grouping
! Case-Mix Grouper
! UNU-CMG Grouper
! Costing Tool! CCM Version 2.0-UKM/UNU
! Costing Template for Hospital Base-Rates
! Costing Template for National Tariff
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Weaknesses of Current Case-mix Groupers ..
! Not designed to group sub-acute and chroniccases
! Sub-acute cases
!Very complicated Cases
! Moderately long stay cases
! Chronic cases
! Mental illness
! Long term rehabilitation
! Social welfare cases
!Very long stay cases
Weaknesses of Current Case-mix Groupers
! Produced unhomogenous DRG groups
! Tariff developed unsuitable for payment of
! Chronic Cases
! Cases with Prostheses
! E.g Hip Replacement. Below Knee Amputation
! Cases with special investigations
! E.g MRI/CT Scan
! Cases with special medications
! Chemotherapy
! Groupers do not have local costweights
! International Cost-weight international does not reflectactual cost locally
! Tariff using uncustomised costweights are unstable
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Weaknesses of Current Case-mix Groupers
! Logic of grouper difficult to be modfied whencoding rules changed! Diagnosis ICD-11 from 2013 (Additional 7,800 codes Dx)
! Procedure ICHI from 2012 (WHO Procedural Classification)
! Severity level cannot be modified! Severity level remains the same
! Depend on the private companies
! Source code held by vendor
UNU-CBG:The New Casemix Grouper
! Grouper developed by researchers from United NationsUniversity
! UNU-International Institute For Global Health (Kuala Lumpur)
! UNU-International Institute For Software Technology (Macau)
! Research and Collaboration
! ITCC- International Training Centre on Case-Mix and Clinical Coding
! MOH of Developing Countries
! Asia Pacific Network of FIC
! WHO-FIC (ICD-10 and Procedure Classifications)
! Owned and Maintained by United Nations University
! United Nations University! United Nations Agency
! Non-for Profit and No Commercial Interest
!
Priority to support developing countries to achieve MDGs
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What is UNU-Case-Mix Grouper?
!
Universal Grouper
! Cover all types of patients care
! Acute (In-patient/Outpatient)
! Sub-Acute (Moderately complex cases)
! Chronic Case (Long Stay Cases)
!
Dynamic Grouper
!
Total number of CBGs can be set-according to need of the country
! Severity level is not static
! Depending on types of patient care
! I to III
! I to IV
! I to IX
! I to X
! Very refined classifications
!
Advance Grouper
! Can be used with future changes in diagnosis and procedure classifications (ICD-11and ICHI classifications
EIGHT COMPONENTS OF UNU-CASEMIXGROUPER
UNU-GROUPER
ACUTE
SUB-ACUTE
CHRONIC
SPECIALPROCEDURES
SPECIALPROSTHESES
SPECIALDRUGS
SPECIALINVESTIGATIONS
AmbulatoryPackage
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CASE-MIX MAIN GROUPS(CMGs)
! CMGs are the first level of classifications
! Labels in Alphabet (A to Z)
! Mostly equivalent to Chapters in ICD-10
! Correspond to Body Systems and Payment Package
! 31 CMGs in UNU Grouper
! 22 Acute Care CMGs
! 2 Ambulatory CMGs
! 2 Subacute and Chronic CMGs
! 4 Special CMGs
! 1 Error CMGs
! Total DRGs (CBGs)= 1,220 (Range: 314-1,250)
Case-Based Groups (CBGs)
! Second level of classification
! Organised in 5 alpha-numeric code! One letter and 4 numbers
! First Digit refers to CMG (Casemix Main Groups)
! Second Digit refer to Case-Type
! Third and Fourth Digit refer to specific DRG called
CBG
! Fifth Digit refer to severity level and resourceintensity level for specific package
! Consists of Medical/Surgical/Package Groups
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UNU-IIGH Case-Mix Grouper-SERVICES COVERED
! Hospital In-patient
! Day Care Surgery
! Specialist Clinic
! Emergency Room
! General Out-patient
! Rehabilitation
! Chemotheraphy and
Radiotherapy
! Mental Health Servicesand Procedures
! Chronic cases
! Long Stayingpatients
! Specific PackageGroups$ Package Out Patient
$ Prostheses
$ Drugs
$ Procedures
$ Investigations
UNU-IIGH CAPACITY BUILDINGPROGRAMME ON CASE-MIX
SYSTEM
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UNU-IIGH CAPACITY BUILDINGPROGRAMME ON CASE-MIX: The Benefits
! Softwares!
Digital Coding Tool-Data Tool Version 2.0
! UNU Case-mix CBG Grouper
! UNU-Code Assist Advance Coding Tool for Verifications
! Clinical Costing Software- Version 2.1
! Costing Template Software for Development of Hospital Base-Rates
! Costing Template Software for Development of National Tariff
! Access to DRG Logic of UNU Case-Mix Grouper!
MOH will have access to the UNU DRG Logic for futuredevelopment
! Training of MOH staff to use UNU DRG Logic for refinement ofcasemix groupings
! Joint Development of Future Case-Mix Grouper
List of UNU-IIGH TrainingWorkshops ( Three Days)
! Workshop 1
! Introduction to Case-MixSystem
! Workshop 2
! Coding of Diagnosis andProcedures for Case-Mix
! Workshop 3
! Installation and Maintenance of
UNU-IIGH Case-mix Software
! Workshop 4
! Case-mix Costing
! Workshop 5
! Clinical Pathways in Case-Mix
! Workshop 6
! Case-Mix Data Analysis
! Workshop 7
! Case-mix Costing Analysis
! Workshop 8
!
Customisation of UNU-IIGH Case-mix Software
! Workshop 9
! Development of Case-mix TariffFor Provider Payment
! Workshop 10
! Presentation of Final Results andNational Roll-out
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UNU-IIGH Case-Mix Grouper
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Clinical Costing Software
Countries working with UNU-IIGH on Casemix
!Asia! Indonesia
! Philippines
! Mongolia
! Vietnam! Malaysia
! Middle East
! Yemen
! United Arab Emirates
! Saudi Arabia
! South America
! Uruguay
! Chile
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Conclusion
! Casemix system is an important tool to ensure sustainability ofsocial health financing programme
! Lack of capacity and inaccessibility to low cost but reliablegroupers are two major obstacles in case-mix implementation
! Most commercial groupers are costly and cannot be customised tomeet needs of developing countries
! UNU-CBG Case-mix Grouper: Universal, Dynamic and Advance
Grouper specially developed to support implementation of case-mixsystem in developing countries
! UNU-IIGH offer a complete package (capacity development/softwares) to facilitate implementation of case-mix system for indeveloping countries