McNutt Robert, Johnson Tricia J, Odwazny Richard, Remmich Zachary, Skarupski Kimberly, Meurer Steven, Hohmann Samuel, Harting Brian
Section of Medical Informatics and Patient Safety Research, Rush University Medical Center, Chicago, Illinois 60612, USA.
Qual Manag Health Care. 2010 Jan-Mar;19(1):17-24. doi: 10.1097/QMH.0b013e3181ccbd07.
In October 2008, the Centers for Medicare & Medicaid Services reduced payments to hospitals for a group of hospital-acquired conditions (HACs) not documented as present on admission (POA). It is unknown what proportion of Medicare severity diagnosis related group (MS-DRG) assignments will change when the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis code for the HAC is not taken into account even before considering the POA status.
The primary objectives were to estimate the proportion of cases that change MS-DRG assignment when HACs are removed from the calculation, the subsequent changes in reimbursement to hospitals, and the attenuation in changes in MS-DRG assignment after factoring in those that may be POA. Last, we explored the effect of the numbers of ICD-9-CM diagnosis codes on MS-DRG assignment.
We obtained 2 years of discharge data from academic medical centers that were members of the University Health System Consortium and identified all cases with 1 of 7 HACs coded through ICD-9-CM diagnosis codes. We calculated the MS-DRG for each case with and without the HAC and, hence, the proportion where MS-DRG assignment changed. Next, we used a bootstrap method to calculate the range in the proportion of cases changing assignment to account for POA status. Changes in reimbursement were estimated by using the 2008 MS-DRG weights payment formula.
Of 184,932 cases with at least 1 HAC, 27.6% (n = 52,272) would experience a change in MS-DRG assignment without the HAC factored into the assignment. After taking into account those conditions that were potentially POA, 7.5% (n = 14,176) of the original cases would change MS-DRG assignment, with an average loss in reimbursement per case ranging from $1548 with a catheter-associated urinary tract infection to $7310 for a surgical site infection. These reductions would translate into a total reimbursement loss of $50 261,692 (range: $38 330,747-$62 344,360) for the 86 academic medical centers. Those cases, for all conditions, with reductions in payment also have fewer additional ICD-9-CM codes associated.
Removing HACs from MS-DRG assignment may result in significant cost savings for the Centers for Medicare & Medicaid Services through reduced payment to hospitals. As more conditions are added, the negative impact on hospital reimbursement may become greater. However, it is possible that variation in coding practice may affect cost savings and not reflect true differences in quality of care.
2008年10月，美国医疗保险和医疗补助服务中心降低了对一组未在入院时记录（POA）的医院获得性疾病（HAC）的医院支付费用。在考虑POA状态之前，当不考虑HAC的国际疾病分类第九版临床修订本（ICD-9-CM）诊断代码时，医疗保险严重度诊断相关组（MS-DRG）分配的变化比例尚不清楚。
主要目的是估计在计算中去除HAC后MS-DRG分配发生变化的病例比例、随后医院报销的变化以及在考虑可能为POA的病例后MS-DRG分配变化的衰减。最后，我们探讨了ICD-9-CM诊断代码数量对MS-DRG分配的影响。
我们从大学卫生系统联盟成员的学术医疗中心获取了两年的出院数据，并识别出所有通过ICD-9-CM诊断代码编码的7种HAC中的一种的病例。我们计算了每种病例在有和没有HAC情况下的MS-DRG，从而得出MS-DRG分配发生变化的比例。接下来，我们使用自助法计算考虑POA状态后分配变化的病例比例范围。使用2008年MS-DRG权重支付公式估计报销变化。
在184,932例至少有一种HAC的病例中，27.6%（n = 52,272）在不将HAC纳入分配的情况下MS-DRG分配会发生变化。在考虑那些可能为POA的情况后，7.5%（n = 14,176）的原始病例MS-DRG分配会发生变化，每例报销平均损失从导管相关尿路感染的1548美元到手术部位感染的7310美元不等。这些减少将转化为86家学术医疗中心总计50,261,692美元的报销损失（范围：38,330,747 - 62,344,360美元）。对于所有情况，那些报销减少的病例相关的额外ICD-9-CM代码也更少。
从MS-DRG分配中去除HAC可能通过减少对医院的支付为医疗保险和医疗补助服务中心节省大量成本。随着更多情况的增加，对医院报销的负面影响可能会更大。然而，编码实践的差异可能会影响成本节省，并且不能反映医疗质量的真正差异。
