Steinbusch Paul J M, Oostenbrink Jan B, Zuurbier Joost J, Schaepkens Frans J M
Erasmus Medical Centre Rotterdam, Institute for Health Policy and Management, 3000 DR Rotterdam, The Netherlands.
Health Policy. 2007 May;81(2-3):289-99. doi: 10.1016/j.healthpol.2006.06.002. Epub 2006 Aug 14.
With the introduction of a diagnosis related group (DRG) classification system in the Netherlands in 2005 it has become relevant to investigate the risk of upcoding. The problem of upcoding in the US casemix system is substantial. In 2004, the US Centres for Medicare and Medicaid estimated that the total number of improper Medicare payments for the Prospective Payment system for acute inpatient care (both short term and long term) amounted to US$ 4.8 billion (5.2%). By comparing the casemix systems in the US, Australian and Dutch healthcare systems, this article illustrates why certain casemix systems are more open to the risk of upcoding than other systems. This study identifies various market, control and casemix characteristics determining the weaknesses of a casemix reimbursement system to upcoding. It can be concluded that fewer opportunities for upcoding occur in casemix systems that do not allow for-profit ownership and in which the coder's salary does not depend on the outcome of the classification process. In addition, casemix systems in which the first point in time of registration is at the beginning of the care process and in which there are a limited number of occasions to alter the registration are less vulnerable to the risk of upcoding. Finally, the risk of upcoding is smaller in casemix systems that use classification criteria that are medically meaningful and aligned with clinical practice. Comparing the US, Australian and Dutch systems the following conclusions can be drawn. Given the combined occurrences of for-profit hospitals and the use of the secondary diagnosis criterion to classify DRGs, the US casemix system tends to be more open to upcoding than the Australian system. The strength of the Dutch system is related to the detailed classification scheme, using medically meaningful classification criteria. Nevertheless, the detailed classification scheme also causes a weakness, because of its increased complexity compared with the US and Australian system. It is recommended that researchers and policy makers carefully consider all relevant market, control and casemix characteristics when developing and restructuring casemix reimbursement systems.
2005年荷兰引入了诊断相关分组（DRG）分类系统，因此对编码升级风险进行调查变得很有必要。美国病例组合系统中的编码升级问题相当严重。2004年，美国医疗保险和医疗补助服务中心估计，急性住院护理（短期和长期）前瞻性支付系统中不当医疗保险支付的总数达48亿美元（占5.2%）。通过比较美国、澳大利亚和荷兰医疗系统中的病例组合系统，本文阐述了为何某些病例组合系统比其他系统更容易出现编码升级风险。本研究确定了决定病例组合报销系统易受编码升级影响的各种市场、控制和病例组合特征。可以得出结论，在不允许营利性所有权且编码员薪酬不取决于分类过程结果的病例组合系统中，编码升级的机会较少。此外，登记的第一个时间点在护理过程开始时且更改登记的机会有限的病例组合系统，较不易受到编码升级风险的影响。最后，使用具有医学意义且与临床实践相符的分类标准的病例组合系统，编码升级风险较小。比较美国、澳大利亚和荷兰的系统，可以得出以下结论。鉴于营利性医院的存在以及使用次要诊断标准对DRG进行分类，美国病例组合系统往往比澳大利亚系统更容易出现编码升级。荷兰系统的优势在于其详细的分类方案，使用了具有医学意义的分类标准。然而，详细的分类方案也导致了一个弱点，因为与美国和澳大利亚系统相比，其复杂性增加。建议研究人员和政策制定者在开发和重组病例组合报销系统时，仔细考虑所有相关的市场、控制和病例组合特征。
