Korea Journal of Hospital Management (한국병원경영학회지)

Korean Society of Hospital Management (한국병원경영학회)
권호 표지

The analysis of medical care behaviors influencing New Diagnosis-Related Groups (DRG) based payment - focused on hospitalized patients with medical illness

신포괄수가에 영향을 미치는 의료행태 요인 분석 - 내과 입원환자 중심으로

  • Lee, Kyunghee (Department of Healthcare Management, Eulji University of Korea) ;
  • Wi, Seung Bum (Department of Internal Medicine, Seoul Medical center, Seoul Metropolitan Government) ;
  • Kim, Suk Il (College of Medicine, the Catholic University of Korea) ;
  • Choi, Byoong Yong (Department of Internal Medicine, Seoul Medical center, Seoul Metropolitan Government)
  • 이경희 (을지대학교 의료경영학과) ;
  • 위승범 (서울특별시 서울의료원 내과) ;
  • 김석일 (가톨릭대학교 의과대학 예방의학교실) ;
  • 최병용 (서울특별시 서울의료원 내과)
  • Received : 2020.04.23
  • Accepted : 2020.06.15
  • Published : 2020.06.30
Download PDF
⟨ Previous Next ⟩

Abstract

Purpose: The purpose of this study is to investigate medical care behaviors influencing accuracy of the payment based New diagnosis-related groups (DRG) compared to fee for service (FFS) in hospitalized patients with medical illness. Methodology: In order to estimate the difference in medical costs between New DRG and FFS depending on medical care behaviors, medical records and hospital claims data (n=4,232) were utilized, which were collected from a single public hospital during the first-half of 2018. Data were analyzed by descriptive statistics, t-test, chi-square test, and multivariate binary logistic regression. Findings: The average difference in medical costs between New DRG and FFS were KRW 506,711±13,945 with incentives and KRW -51,506±12,979 without incentives, respectively. Forty-four point two percent (44.2%, n=1,872) of total subjects were shown to have negative compensation in overall medical costs with New DRG compared to the costs with FFS. Medical care behaviors that affected on the negative compensation were the presence of severe bed sores on admission, medical consultations, death, operations, medications and laboratory or imaging tests with unit price over KRW 100,000, hospital-acquired complications or underlying comorbidities, elderly patients (≧65 years), and hospitalized for more than average inpatient days defined by New DRG (p<0.001). The difference in average medical cost between New DRG and FFS for a group with mild illness was KRW -11,900±10,544, whereas it was KRW -196,800±46,364 for a group with severe illness (p<0.0001). Practical Implications: These findings suggest that New DRG payment model without incentives may incompletely cover the variation of medical costs in real clinical practice. Therefore, policy makers need to consider that the current New DRG reimbursement should be focused and refined to improve accuracy of payment on medical care resources utilized in severe and complex medical conditions.

Keywords

References

  1. 강길원. [주제토론 1] 우리나라 진료비지불보상제도의 개혁: 신포괄수가제 도입의 의의와 주요 논쟁점. 한국보건행정학회 학술대회논문집, 2010(2), 21-37.
  2. 건강보험심사평가원. (2020). 신포괄지불제도 시범사업지침
  3. Song HS, A Study on Perception, Attitude, and Satisfaction level of the Subjects of DRG Payment System. KISS, 2013.5
  4. Shin ES. The Effect of New Diagnosis Related Group based Payment on the Length of Stay [dissertation]. Seoul : The Catholic university: 2017
  5. Kim YY. Effect of the Korean Case Payment System on the Length of Stay and Readmission [dissertation]. Seoul : Seoul National university: 2015
  6. Son CW, Effects of New Diagnosis Related Group based Payment on Service Provision and Quality of Care[dissertation]. Seoul : Seoul National university: 2015
  7. Kim GD, Effects of New Diagnosis Related Group based Payment on Efficiency of Hospitals[dissertation]. Seoul : Seoul National university:2017
  8. 강길원, 최숙자, 전윤희, 강민석. 신포괄수가 조정기전개발 연구. 건강보험심사평가원.2014.
  9. Yun HJ, Study on the Meadical Services Granted in Accordance with The Applicable Reduction of The DRG Payment System [dissertation]. Seoul : Konkuk university. 2016
  10. Burns LR, Wholey DR. The effects of patient, hospital, and physician characteristics on length of stay and mortality. Med Care. 1991;29(3):251 https://doi.org/10.1097/00005650-199103000-00007
  11. Rogers WH, Draper D, Kahn KL, et al. Quality of care before and after implementation of the DRG-based prospective payment system. A summary of effects. JAMA. 1990;264(15):1989 https://doi.org/10.1001/jama.1990.03450150089037
  12. Siess M, Bartkowski R, Hermanek P, et al. Auswirkungen des DRG basierten Entgelt-systems. Welcher Handlungsbedarf besteht fur den Chirurgen? [Effects of the DRG-based payment system. What action requirement exists for the surgeon?]. Chirurg. 2001;72(2):30 https://doi.org/10.1007/s001040051264
  13. Kusserow RP, Steeley BL. DRG "creep". Pitfalls and sanctions to avoid. Consultant. 1989;29(3):93-5, 98-9.
  14. Carter GM, Newhouse JP, Relles DA. How much change in the case mix index is DRG creep?. J Health Econ. 1990;9(4):411 https://doi.org/10.1016/0167-6296(90)90003-L
  15. Fitzgerald JF, Fagan LF, Tierney WM, Dittus RS. Changing patterns of hip fracture care before and after implementation of the prospective payment system. JAMA. 1987;258(2):218 https://doi.org/10.1001/jama.1987.03400020060031
  16. A research paradigm for severity of illness: Issues for the diagnosis-related group system. Paul M. Gertman and Steven Lowenstein, Health Care Financ Rev. 1984 Nov; 1984(Suppl): 79-90].
  17. Dismuke C.E, Sena V. Has DRG Payment Influenced The Technical Efficiency and Productivity Of Diagnostic Technologies In Portuguese Public Hospitals? An Empirical Analysis Using Parametric And Non-Parametric Methods. Health care management science 1999;2(2); 107-116. https://doi.org/10.1023/A:1019027509833
  18. Rogers WH, Draper D, Kahn KL, Keeler EB, Rubenstein LV, Kosecoff J et al. Quality of care before and after implementation of the DRG-based prospective payment system. A summary of effects. JAMA 1990;264(15):1989-1994. https://doi.org/10.1001/jama.1990.03450150089037
  19. Choi JW, Perspectives on cost containment and quality of health care in the DRG payment system of Korea. J Korean Med Assoc. 2012; 55(8): 706-709. https://doi.org/10.5124/jkma.2012.55.8.706
  20. Kim NL. Perception on New Bundling Payment Program among Physicians of Regional Public Hospitals in Korea [dissertation]. Seoul : Hanyang university; 2013
  21. Hwang SH. Dong-Kwan Oh,Myo-Jeong Kim, Choon-Seon Park,Quality of care for public and private hospitals in Korea, Public Health Affairs 2017;1(1): 145-156. https://doi.org/10.29339/pha.1.1.145
  22. Song GY. 의료시장 개방에 대비한 민간병원의 경쟁력 강화방안 연구 Journal of the Korean hospital association, 2004
  23. Ospel JM, Goyal M. Cherry-picking the Wrong Patients has to be Avoided at all Cost!. Clin Neuroradiol. 2020;30(1):43. doi:10.1007/s00062-020-00881-7
  24. Humbyrd CJ. The Ethics of Bundled Payments in Total Joint Replacement: "Cherry Picking" and "Lemon Dropping". J Clin Ethics. 2018;28(1):62
  25. Busse R, Geissler A, Aaviksoo A, Cots F, Hakkinen U, Kobel C, et al. Diagnosis related groups in Europe: moving towards transparency, efficiency, and quality in hospitals? BMJ. 2013;346:f3197. https://doi.org/10.1136/bmj.f3197
  26. Shin DG, Lee C, Lee S, Kang J, Sun Y, Park E. Differences of Medical Costs by Classifications of Severity in Patients of Liver Diseases 2013;23(1):35-43. https://doi.org/10.4332/KJHPA.2013.23.1.035
  27. Kim SI, et al. A Study on Adequacy of Medical Fee in New DRG-based Prospective Payment System.Korean Medical Association. 2018
  28. Louis, D. Z., Yuen, E. J.,Braga, M., Cicchetti, A., Rabinowitz, C., Laine, C. et al. Impact of a DRG-based hospital financing system on quality and outcomes of care in Italy. HSR 1999; 34(1 Pt 2); 405-415
  29. R Koivuniemi, M Leirisalo-Repo, R Suomalainen, H Piirainen, L Paimela. Infectious Causes of Death in Patients With Rheumatoid Arthritis: An Autopsy Study.. Scand J Rheumatol. Jul-Aug 2006;35(4):273-6.] https://doi.org/10.1080/03009740600556258