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What DRG versions available in CHIA Inpatient Case Mix Data?

Discover the evolution of Diagnosis Related Groups (DRGs) in Massachusetts Inpatient Hospital Discharge Data (HDD) over 26 years, including AP-DRG and APR-DRG versions. Understand the differences and significance of each version in classifying patients for payment systems.

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What DRG versions available in CHIA Inpatient Case Mix Data?

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  1. WhatDRGversionsavailablein CHIAInpatient CaseMixData?

  2. Review: Definition of DRG DiagnosisRelatedGroup Aclassification system thatgroupspatients according to diagnosis, type of treatment, age, and other relevantcriteria. Under the prospective payment system, hospitalsare paid a set fee for treating patients in a single DRG category, regardless of the actual cost of carefor the individual. Source:CMS http://www.cms.gov/apps/glossary/default.asp

  3. Overthe Past30 years Multiple Versionsof DRGs have been Created andRefined TheThreeMostCommonlyUsedDRGs Decade(2004-2015)in HDD • AllPatientsDiagnosisRelatedGroups AP-DRG AllPatientsRefinedDiagnosisRelatedGroups APR-DRG Medicare(CMS)DiagnosisRelatedGroups CMS-DRG • •

  4. 26 Year (1988-2015) History of Diagnosis Related Group(DRG) Versions inMassachusetts InpatientHospitalDischarge Data(HDD) HDD Fiscal Year AP-DRG Version 12 AP- DRG Version 14.1 AP- DRG Version 18 AP-DRG Version 21 AP-DRG Version 25.1 APR- DRG Version 12 APR- DRG Version 15 APR- DRG Version 20 APR-DRG Version 26.1 APR- DRG Version 30 Former HCFA(now CMS)DRG Version2 FormerHCFA (nowCMS) DRGVersion 8 VHAF- DRG Version 24 VHAF- DRG Version 25 CMS- DRG Version 26 CMS- DRG Version 27 CMS- DRG Version 28 CMS- DRG Version 29 CMS- DRG Version 30 CMS- DRG Version 31 CMS- DRG Version 32 2015 X X X X 2014 X X X X 2013 X X X X X X 2012 X X X X X X 2011 X X X X X X 2010 X X X X X X 2009 X X X X X X 2008 X X X X 2007 X X X X 2006 X X X X X 2005 X X X X 2004 X X X X 2003 X X X X 2002 X X X X 2001 X X X X 2000 X X X X X 1999 X X X X X X 1998 X X X X X X 1997 X X X X X X 1996 X X X X X X 1995 X X X X X X 1994 X X X X X X 1993 X X X 1992 X X X 1991 X X X X 1990 X X X X 1989 X X X 1988 X X

  5. Whatisthedifferencebetween the DRGversions?

  6. AP-DRGHistoryandMassachusettsHDDUseTimeline All PatientsDiagnosisRelated Groups (AP-DRG)wasdevelopedin 1987through agreementbetweenNew YorkState DepartmentofHealthand3MHealthInformation SystemsSoftwarein conjunctionwith theNationalAssociationof Children’sHospitals andRelatedInstitutions. AP-DRGsaresimilar to original DRGsdevelopedbyYaleUniversity for CMS,but also includeamoredetailedDRG breakdownfornon-Medicarepatients,particularlynewborns and children.Itsdevelopmentwasdrivenbylegislation institutingDRG-prospectivepaymentforallnon-Medicarepatients andevaluatedto ensureitsapplicabilitytoneonatal,pediatricpatientsand patientswithHIV.The featuresofAP-DRG categoriesrecognizeresourceintensity*associatedwith: • • • • • SixDistinct NeonateBirthWeight Ranges HIV inthepresenceorabsenceof12 related infections Complications andComorbidities /TransplantStatus Differentiation ofFormsofSubstanceAbuse Pediatricmodifications associatedwith,for example,leadpoisoningandcongenitalanomalies Timeline ofAP-DRG Usein MassachusettsHDD AP-DRG 1989 - 2008 Version 12 Version 14.1 AP-DRG 1994-2006 Version 18 Version21 Version 25.1 1988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015 AP-DRG 1994 - 2006 AP-DRG 2006-2015 AP-DRG 2009-2015 DefinitionofResourceIntensity - The relativevolumeand types of diagnostic,therapeutic, and bedservices usedin themanagementof a particular disease.(source: AHRQ https://www.hcup-us.ahrq.gov/db/nation/nis/APR-DRGsV20MethodologyOverviewandBibliography.pdf)

  7. APR-DRGHistoryandMassachusetts HDDUse Timeline AllPatientsRefinedDiagnosisRelated Groups (APR-DRG),developedin1990,shifts focusofDRGsfrominstitutionalresourceintensityto casemix demographics,clinical complicationsandcomorbidities,andmultiplediagnoses.Existingresourceintensity DRGsdid notaddressseverityofillness,riskofmortality,andtheimpactand interaction ofmultiplediagnosesontreatmentdifficulty.WhileCMSlater createdan MS-DRGseverityadjustmentto CMS-DRG,itonlyadjustsforsinglecomplicatingfactors whileAPR-DRGis moreeffective ingroupingbythetruecomplexityofmultiple additionalcomorbidities orcomplicationswithandwithouttheiraddedimpact on resourceuse.TheAPR-DRGincludes: •Fourseverityofillnesssubgroups(Minor,Moderate,Major,Extreme) •Fourriskofmortalitysubgroups(Minor,Moderate,Major,Extreme) •Eachoftheabovesubgroupassignmentstakeintoconsiderationsecondarydiagnosis,interactionbetweensecondary diagnosis,age,principaldiagnosis,complications,comorbidities,ORandnon-ORprocedures. Focus of APR-DRGon interactionof factors Patient Clinical ICD-9-CM Characteristics Aspects Diagnoses Age Surgical PrincipalDiagnosis Gender Discharge Status Secondary Comorbidity Complications Procedures Diagnoses Morethan50% ofU.S.hospitalsuseAPR-DRG.CMS contracted withRAND toevaluateseverity-adjusted DRGsystems APR-DRGranked superiorto all other DRG classification systems.* of5different TimelineofAPR-DRGUseinMassachusettsHDD APR-DRG 1990-1999 Version 12 Version 15 Version20 APR-DRG 2009- 2015 Version 26.1 APR-DRG 2009- 2015 Version 30 1988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015 APR-DRG 1994-2006 APR-DRG 2007-2015 *Wynn BO,ScottM:Evaluationof Severity-AdjustedSystems.PreparedfortheCMSJuly2007,RANDHealth.

  8. CMS-DRG History and Massachusetts HDD Use Timeline The Health Care Financing Administration (HCFA), the predecessor HowCMS-DRGsdifferfromAPR-DRGs?** agency to the Centers for Medicare and Medicaid Services, implemented HCFA-DRGs in 1983 to measure inpatient resource consumptionbytheMedicarepopulation.ThecoreoftheirDRGsystem wasthehealthcare “product”suppliedbyhospitalcareofapatient.The initial architects of the CMS-DRG system established 23 major diagnostic categories (MDCs) as the first level of categorizing these products.*TheMDCswerethensubdividedintoDRGsbasedonfactors suchassurgicalstatus,organsystem,age,symptoms,comorbidities, anddischargestatus.WhilesubsequentmodificationstotheMedicare DRGs includednon-Medicarepatients,thekeyfocusofmodifications hasbeenonproblemsrelatingprimarilytotheelderlypopulation. The VeteransHealthAdministrationVHAF-DRG isbasedontheCMS-DRG withrefinementsby3Mforseverityintheveteranspopulationand non-veteranpopulation. Timeline ofHCFA,VHAF,andCMSDRG UseinMassachusettsHDD HCFA-DRG 1988-1991 HCFA-DRG 1988-2000 VHAF- CMS- Version 8 Versions Versions 24 25 26 27 28 29 30 31 32 1988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015 Version 2 AnnualUpdates DRG DRG * Source:Dr.BrandonBushnell:TheEvolutionofDRGs.AmericanAcademyofOrthopedicSurgeons,http://www.aaos.org/news/aaosnow/dec13/advocacy2.asp ** Source:AllPatientRefinedDRGs,aMethodologyOverview,2006, 3MHIS,https://msmedicaid.acs-inc.com/trainingMaterials/MSAPR-Methodology.pdf

  9. ComparisonofSomeStructural*Differencesbetween Medicare-DRG,AP-DRG,APR-DRGVersions Medicare 12 AP-DRG APR-DRG DRG MultipleComplications andComorbiditiesnot recognized MultipleComplications andComorbiditiesnot recognize MultipleComplications andComorbidities recognized NewbornBirthweight not Used NewbornBirthweight Used NewbornBirthweight Used NoRisk of Mortality Subgroup NoRisk of Mortality Subgroup IncludesRiskof Mortality Subgroup NationalAssociationof Children’sHospitals PediatricModifications Not Included LimitedInclusion of NationalAssociationof Children’sHospitals PediatricModifications CompleteInclusionof NationalAssociationof Children’sHospitals PediatricModifications Limiteduse ofHIV InfectionMDC CompleteuseofHIV InfectionMDC CompleteuseofHIV InfectionMDC * Source:3M Health InformationSystemsResearchReportNo. 5-98

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