Crespin Daniel, Dworsky Michael, Levin Jonathan, Ruder Teague, Whaley Christopher M
Daniel Crespin (
Michael Dworsky, RAND Corporation, Santa Monica, California.
Health Aff (Millwood). 2024 Dec;43(12):1619-1627. doi: 10.1377/hlthaff.2024.00596.
Diagnosis-based payment systems can create incentives to upcode patients to a higher level of severity to increase payment. In some instances, upcoding can be a form of fraud if providers code patients to a higher complexity than is appropriate, whereas in other instances, upcoding can accurately reflect patient acuity. We estimated the increase in Medicare Severity Diagnosis-Related Group (MS-DRG) upcoding during the period 2011-19, using all-payer discharge-level data from five states. During this period, the number of discharges with the highest MS-DRG coding intensity increased by 41 percent. Adjusting for changes in patient characteristics, length-of-stay, and hospital characteristics, we estimated that the increase would have been 13 percent in the absence of changes in coding behavior. We estimated that in 2019, the increase in upcoding (relative to 2011 coding practices) was associated with $14.6 billion in hospital payments, including $5.8 billion from private health plans, $4.6 billion from Medicare, and $1.8 billion from Medicaid. These findings can contribute to the growing body of evidence supporting the design of payment models that limit distortions in payment and resource allocation.
基于诊断的支付系统可能会促使医疗机构将患者编码为更高的严重程度等级，以增加支付金额。在某些情况下，如果医疗机构将患者编码为高于适当水平的复杂性，那么这种高编码可能构成一种欺诈形式；而在其他情况下，高编码可能准确反映患者的病情严重程度。我们利用五个州的全支付方出院数据，估算了2011 - 2019年期间医疗保险严重程度诊断相关组（MS - DRG）高编码的增加情况。在此期间，MS - DRG编码强度最高的出院病例数量增加了41%。在对患者特征、住院时长和医院特征的变化进行调整后，我们估计，如果编码行为没有变化，这一增幅本应为13%。我们估计，2019年，高编码的增加（相对于2011年的编码做法）与医院支付增加146亿美元相关，其中包括来自私人健康保险计划的58亿美元、来自医疗保险的46亿美元以及来自医疗补助的18亿美元。这些发现有助于增加支持设计限制支付和资源分配扭曲的支付模式的证据。
