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Gaming and Sub-acute patients

Explore the challenges of generating accurate data counts for funding in healthcare, including gaming and sub-acute patients. Learn about the impact on various care programs and the need for efficiency and quality control. Understand the difference between gaming and fraud and discover strategies to address these issues in Serbia.

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Gaming and Sub-acute patients

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  1. Gaming and Sub-acute patients Ric Marshall 14.45 - 15.30 Tuesday, 6th December 2011

  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 – • ?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?

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