Gaming. Sub-acute patients.

1. Gaming. Sub-acute patients. RIC AND LINDY

2. Generating additional data counts for more funding • “Paper cases” administrative discharges and readmission in Hungary • Change of care type in NSW. • “Empty cases” in Slovenia • Admitting cases in Emergency Departments and Outpatients – • ?can these be legitimate?

3. DEFINITIONS AND RULES AGED CARE AND MENTAL HEALTH PROGRAMS TRAUMA AND ACUTE ILLNESS DRG INPATIENTS ED PATIENTS BUNDLED OUTPATIENTS FFS AMB PATIENTS PRIVATE AND DISCRETIONARY ELECTIVE?? CHRONIC CARE PROGRAMS SAME DAY INPATIENTS

4. Admitting outpatients as short stay inpatients • Rapid growth in Victoria of same day episodes • Clear evidence of admitting cases that can be treated in ambulatory setting • Cases that can be treated either way becoming all inpatient – eg • dialysis and chemotherapy • REMOVE PAYMENT INCENTIVE - CAPS

5. UPCODING CA$EMAX 1000 500 100 0 70% ACCURACY 30% CREATIVITY – SUBECT TO EDITS

6. DRG creep in Hungary Source: Nagy, J., 1999.

7. Change of care type or discharge and readmission for rehabilitation • How many times per stay? • How many times per day? • Can we pay for them both together? • What is the right time?

8. How to detect and control gaming „The only way to pay doctors is to change the system every three years, because by then they will have found ways to get round it to their own advantage” Bob Evans • All casemix systems adjust the system every year • New cost weights and recalibrated price • Potential to cap or reweight overprovision.

9. Fine tuning of the system:addressing negative effects • Upcoding (creep), “paper” (readmitted) cases • Monitor and control provider reporting of cases • Continuous cost weight revision • Efficiency and quality • Addressing undertreatment (quality/effectiveness): • creating new groups • *DRGs for sophisticated care, but only selected providers • Quicker-sicker problem: readmission before maximum day limit does not pay extra

10. The difference between gaming and fraud • Fraud is repeated offences with intention • Fraud is knowing violation of reporting rules • Fraud is materially profiting from systematic ‘mistakes’ • Fraud is attempting to hide payments claimed that do not relate to a real service

11. QUESTIONS • How can these issues be addressed in Serbia? • What is done now about professional review? • How is fraud detected and controlled?

12. PART 2 Sub acute casemix

13. “SUB ACUTE CARE” • REHABILITATION • PALLIATIVE CARE • GERIATRIC EVALUATION AND MANAGEMENT • PSYCHOGERIATRIC • ??MAINTENANCE (OR NURSING HOME TYPE)?

14. SNAP – SUB ACUTE INPATIENT

15. SNAP – SUB ACUTE AMBULATORY

16. CHANGE OF CARE TYPE ‘REHABILITATION SERVICES’ CARE TYPE ‘ACUTE SERVICES’ DAY OF EPISODE OF CARE OR SPELL

17. CARE PATHS AND CLASSIFICATIONS

18. REHABILITATION CASEMIX

19. REHAB CAN BE ACCESSED • As part of an acute episode (DRG) (usually?) • As a separate “ACUTE” DRG episode • As a separate admission type (where substantial) • Different care type – ‘SUBACUTE’ • As a series of one off referrals from a community provider for eg • PHYSIO, OT, PSYCHOLOGY, SPEECH THERAPY, POD ETC • As a planned package/program of care on an ambulatory basis or combination.

20. The Oz classification smorgasbord

21. TWO EXAMPLE REHAB CLASSIFICATIONS

22. MEASURES OF FUNCTION AVAILABLE FOR CLASSIFICATIONS • ICF – International classification of function – WHO • FIM • Barthels • RUGs

23. Rehabilitation Patient Groups – Ontario 2008 • 83 RPG in the new classification system • Relies on the following data elements where applicable: • 1. Rehabilitation Client Code • 2. Admit Motor Functional Independence Measure (FIM) score • 3. Admit Cognitive FIM score • 4. Patient Age

24. Rehabilitation Patient Groups – Ontario 2008 –1 of 2 (M = motor FIM score; C=cognitive FIM scores)

25. Rehabilitation Patient Groups – Ontario 2008 –2 of 2

26. Victorian Rehabilitation • •Designated Rehabilitation Units • –Agencies are designated for Rehabilitation Units • –10 beds or more and must meet designation criteria • –Paid by per diem grants (or for CRAFT agencies a mix of episode & per diem since 1999) • •Non-Designated • –Payment through Casemix AN-DRG system by WIES

27. CRAFT Development • Objective to develop a casemix classification system for Rehabilitation patients which could be effectively adopted as a casemix funding method • Important therefore that the model meet the following criteria: • –Clinical similarity • –Resource homogeneity • –Administrative ease • –Suitable for funding agencies

28. Functional Status Issues • Functional status is not used in other DRGs, but • Functional status is basic to rehabilitation practice, assessment and theory – • so important to consider in a classification • Main issues with regard to functional status: • Choice of standard measure instrument • Barthel • FIM • Barthel was chosen originally by Clinical Panel of advisers for collection in Victoria. • It can also be mapped to FIM

29. Craft Categories • . Short Stay (overnight stay 1-3 days) • 1 Stroke/NeurologicalAdmission Barthel score <60 • 2 Stroke/NeurologicalAdmission Barthel score ≥ 60 • 3 Orthopaedic Fracture Admission Barthel score < 60 • 4 Orthopaedic Fracture Admission Barthel score ≥ 60 • 5 Orthopaedic Replace Hip/Knee Admission Barthel score < 60 • 6 Orthopaedic Replace Hip/Knee Admission Barthel score 60 – 79 • 7 Orthopaedic Replace Hip/Knee Admission Barthel score ≥ 80 • 8 Other Orthopaedic Admission Barthel score < 60 • 9 Other Orthopaedic Admission Barthel score ≥ 60 • 10 Cardio/Pulmonary • 11 Amputation • 12 Head Injury/Major Multiple Trauma • 13 Spinal • 14 Burns • 15 Other Rehabilitation Admission Barthel score < 60 • 16 Other Rehabilitation Admission Barthel score ≥ 60

30. Casemix Rehabilitation and Funding Tree (CRAFT)

31. Options for Funding • Episode Costs -Payment for an episode of care • Advantages: • Promotes and rewards efficiencies and standard practice across agencies • Provides a clearer benchmark for units for planning, funding and the evaluation of services– • Disadvantages: • Variability in LOS (“Quicker And Sicker” risk) • Per Diem Costs -Payment based on a day rate– • Advantages:– • More closely approximates existing care • May better reflect service differences– • Disadvantages:– • Does not encourage efficiencies or standard practice across agencies • Consultations with field –episode preference

32. NON-ADMITTED DIFFERENCES • Lower? cost structures (usually , not necessarily): • Can be a substitute program for admitted or • A separate different care model (eg voc placement) . • Community can be an essential part of the rehab. • Goals can be staged – series of sub programs. • Function dependent goals and decision points. • Combinations of services can change depending on progress. • Dx can change – certainly needs can.

33. PAYING FOR NON-ADMITTED REHAB Minimum requirements Oz • Criterion 1 Rehabilitation care provided by a specialist rehabilitation team on an admitted or non-admitted basis in a specialist rehabilitation unit (a separate physical space.) • and • Criterion 2 Rehabilitation care provided by a multi-disciplinary team which is under the Clinical management of a consultant in rehabilitation medicine or equivalent. • and • Criterion 3 Rehabilitation care provided for a person with an impairment and a disability and for whom there is reasonable expectation of functional gain. • and • Criterion 4 Rehabilitation care for whom the primary treatment goal is improvement in functional status. • and • Criterion 5 Rehabilitation care which is evidenced in the medical record by: • an individualised and documented initial and periodic assessment of functional ability by use of a recognised functional assessment measure. • an individualised multidisciplinary rehabilitation plan which includes negotiated rehabilitation goals and indicative time frames. MORE DETAIL

34. MENTAL HEALTH CARE AND CASEMIX

35. Mental Health Services as a Part of Health Care? (1/2) • We spend between 7 and 13% of recurrent health expenditure on mental health as the primary condition. • Compared with cardiovascular diseases (10.9%), nervous system disorders (9.9%), musculoskeletal diseases (9.2%), injuries (8.0%), respiratory diseases (7.5%) and oral health (6.9%). AIHW (Mental health services in Australia 2004–05). • The big growth factor in the last decade has been increased expenditure on drugs for depression. • DEPRESSION has highest burden of disease disease where Quality of Life is factored in (rather than mortality).

36. Mental Health Services as a Part of Health Care? (2/2) • Acute hospitals • MH alone 3% of separations, 9.7% of bed-days • MH+D&A 3.7% of separations, 10.7% of bed-days. • Special inpatient facilites • Mental health is one of the few clinical specialties where a proportion is done in specialised inpatient and outpatient treatment services. • These are operated both on a voluntary and compulsory basis – and they may involve legal incarceration. • $534AUD million pa in Australia • Private sector hospitals / clinics • Mental health is one of their biggest products • Both as direct care and as a comorbidity with other conditions – liaison psychiatry – major issue.

37. What is the scope of mental health services? (1/2) • Drug and alcohol services are grouped together as the same service statistics? • Community support services – even such things as housing assistance can be included in mental health care. • Rehabilitation and social independence programs • Cognitive diseases often associated with aging • Alzheimers, Senile dementias etc – may be here or in Aged care. • “Psychogeriatric” can be siloed as a completely different care stream.

38. What is the scope of mental health services? (2/2) • “Developmental” disorders • Autistic disorders • Severe learning disorders • Hyperactivity • What about mental health as a CC of other conditions? • Mental health diagnoses and their related treatments are one of the most common comorbidity factors in the treatment of physical conditions. • Generally these costs are not taken into account in the estimates on mental health expenditure. • Some patients can be treated for mental health problems when actually not eligible from their health insurance status – by being admitted for a less urgent physical condition.

39. Casemix classifications of mental health? (1/2) • DRG type Classifications • AR-DRGs • CMS DRGs • HRGs • etc • Ambulatory and community classifications • APCs?? • DBGs • Care path based classifications • Care packages • Care programs • DSM 4 Procedure axis

40. Casemix classifications of mental health? (2/2) • Mental health status classifications - eg • HoNOS - http://www.crufad.com/phc/honosglossary.htm • - http://pb.rcpsych.org/cgi/content/full/29/11/419/TBL1?ck=nck • CIDI – DIS http://www.crufad.unsw.edu.au/cidi/cidi.htm • BDI – HAS – etc. etc. http://www.swin.edu.au/victims/resources/assessment/affect/bdi.html • General assessment tools – mental status components. • Sf36, SF12 - http://www.crufad.com/phc/sf-12.htm • FIM - http://www.tbims.org/combi/FIM/index.html • ICF - http://www.who.int/classifications/icf/site/onlinebrowser/icf.cfm • Mixed classifications • Combination of inputs relating to patient characteristics and Px’s • DSM

41. The World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) • The CIDI is a comprehensive, fully-structured interview designed to be used by trained lay interviewers for the assessment of mental disorders according to the definitions and criteria of ICD-10 and DSM-IV. • The CIDI allows the investigator to:- Measure the prevalence of mental disorders- Measure the severity of these disorders- Determine the burden of these disorders- Assess service use- Assess the use of medications in treating these disorders- Assess who is treated, • http://www.hcp.med.harvard.edu/wmhcidi/

42. Is Mental Health so different from other health services?

43. SOME PRACTICAL PROBLEMS • Discrete funding silos • Continuity gaps • Availability versus suitability • Information barriers • Privacy • Professional territoriality • Patient disempowerment – stigma - chronicity • Accessible/current best practice protocols

44. Why do some insurers want to limit access to MH care? • Differential eligibility restrictions – eg • Longer wait for coverage for mental health as a pre-existing condition. • Exclusion of mental health coverage. • USA’s parity legislation – THE OBAMA REFORMS • Expenditure caps – lifetime hospital admission cap.

45. USA CMS – INPATIENTSEpisode and per-diem mixture

46. AUSTRALIAN CASE STUDY“YOU CAN KEEP SOME OF THE PEOPLE HAPPY SOME OF THE TIME….”

48. http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-pubs-d-casemix-toc~mental-pubs-d-casemix-mhhttp://www.health.gov.au/internet/main/publishing.nsf/Content/mental-pubs-d-casemix-toc~mental-pubs-d-casemix-mh

49. AR-DRG CATEGORIES U40Z Mental Health Treatment, Sameday, W ECT U60Z Mental Health Treatment, Sameday, W/O ECT U61ASchizophrenia Disorders W Mental Health Legal Status U61B Schizophrenia Disorders W/O Mental Health Legal Status U62A Paranoia & Acute Psych Disorder W Cat/Sev CC or W Mental Health Legal Status U62B Paranoia & Acute Psych Disorder W/O Cat/Sev CC W/O Mental Health Legal Status U63A Major Affective Disorders Age >69 or W (Catastrophic or Severe CC) U63B Major Affective Disorders Age <70 W/O Catastrophic or Severe CC U64Z Other Affective and Somatoform Disorders U65Z Anxiety Disorders U66Z Eating and Obsessive-Compulsive Disorders U67Z Personality Disorders and Acute Reactions U68Z Childhood Mental Disorders • 12 CATEGORIES • DX BASED ICD • LEGAL • NO D & A • LARGE DATABASE FOR GROUPER CALIBRATION • INPATIENT ONLY

50. DRGs/HRGs and Mental Health • Politically rejected for payment because “poor predictor of individual service cost” • Are other specialities so sensitive?? • Not usually considered for use with other variables • Facility – level – availability support. • Extended care programs – capitation – add on