Abstract It is noted that the major driving forces of development of subacute care market include the prospective payment system such as DRGs TW-DRGs payment policy started in January of 2010, and will be completely implemented during the coming 5 years. And it is expected that some of the untoward reactions of the medical care providers will change its structure and behavior in response to the financial fluctuation and operation risks¡Athis conditions give birth to the subacute care market. The purpose of the study includes (1)Estimation of the potential subacute care market raising by the impletement of the TW-DRGs payment policy. (2)How can the present medical service providers pave the way to joint the subacute care market. (3)Is there a chance to establish a new service model according to the operation circumstance in Taiwan!? Our study of subacute care and these issures involved an extensive literatures and documents review as well as interviews with knowledgeable experts from around the sourthern part of the country (including professor of medical college and management college, CEO of hospitals and nursing facilities and officer of public health department ) quantiatative analysis of the collected data was done. We came to a conclusion that there will be enomerous demand of subacute care market and there is no so-called subacute care provider noted in the Taiwan medical service system. The imbalance between demand and supplyment will lead to a chance of developing a new service model acccoding to the specific requirement of the people. Since patients and providers will response to the payment system designed and executed by the policy-maker of the government, our suggestion of policy implication about setting up the subacute care system include : 1. Defining subacute care clearly. 2. Recognizing proper requirements of providers. 3. Identifying rational clinical approach. 4. Improving patient placement and transfer process. 5. Ensuring that the care is reimbursed adequately and appropriately. Key Words: TW-DRGs¡ASubacute Care¡AStrategy

Abstract To investigate the reaction of hospitals in burn patient to the announcement of the coming diagnosis related groups (DRGs) payment system in 2014. The claimed data of 506 inpatients from 2009 to 2010 was used for the longitudinal analyses. The average length of stay (ALOS) and medical expenses of each burn patient were compared with the baseline data of 2009. The year effect was analyzed by the generalized estimating equation model. Comparing to the data in 2009, the average length of stay (ALOS) was increased, but medical expenses were decreased. The limitation of the scheme such as insufficient classification of case severity and hospital creep are also discussed. Medical expenses are different in different property of hospitals. Similar resource intensity is unfortunately seriously misunderstood as unified single federal rate in Taiwan. It is concluded that the coming DRGs payment system may changed hospital behavior. This change of hospital behavior may influence the quality of health care.

Le calcul des coûts des séjours et des pathologies peut être abordé selon différentes perspectives : les coûts à charge des systèmes sociaux, des patients ou des hôpitaux. La thèse est centrée sur cette dernière approche. Les DRGs représentent la tentative la plus récente de maîtriser la croissance des dépenses des hôpitaux en introduisant une médicalisation partielle des mécanismes de financement. La connaissance des coûts des pathologies peut permettre aux hôpitaux de participer à l’élaboration des tarifs par pathologie en faisant partie d’un échantillon de référence des coûts hospitaliers. En cas de financement basé sur les pathologies, les hôpitaux doivent pouvoir comparer le coût des séjours au chiffre d’affaires octroyé et s’y adapter. Cet intérêt s’accroît en cas de financement forfaitaire, évolution qui semble se profiler en Belgique tout comme dans d’autres pays. En décrivant une méthodologie de calcul des coûts par pathologie et en indiquant la manière dont ceux-ci pourraient contribuer à la création d’une échelle de cost-weights, notre thèse incite les hôpitaux à adopter une politique proactive dans le domaine du financement des hôpitaux. Les comparaisons de coûts hospitaliers pour évaluer la gestion sont pratiquées depuis de nombreuses années. Cependant, ce « benchmarking » est imparfait car il ne prend pas en compte la lourdeur des patients pris en charge. La standardisation des coûts sur base du case-mix de l’hôpital suppose un préalable important : l’existence d’une échelle de cost-weights issue d’un échantillon représentatif d’hôpitaux. Si cette situation n’est pas encore totalement rencontrée en Belgique, il est néanmoins possible de suggérer une voie de réflexion. La simulation inspirée de la méthodologie suisse à partir d’un échantillon de quatre hôpitaux belges présentée dans le cadre de cette thèse, est une première avancée en ce sens. Un des problèmes majeurs de la gestion hospitalière est d’intéresser les prescripteurs et les prestataires à un contrôle de gestion essentiellement financier. Depuis quelques années, de nombreux efforts visent à intégrer de nouveaux indicateurs de performance dans les tableaux de bord. L’analyse des coûts des pathologies et de la variabilité des cas permet d’entamer un dialogue entre gestionnaire et corps médical. En abordant différentes études (apport des nomenclatures dans le calcul des coûts par pathologie, mesure des coûts associés aux bactériémies nosocomiales, analyse des facteurs médico-sociaux expliquant les surcoûts des patients outliers, analyse de la relation entre le coût et la sévérité des cas, comparaison des coûts de production et des pratiques médicales), nous avons voulu montrer l’importance d’associer une approche médicalisée à des raisonnements économiques. Si elle se développe, cette approche est susceptible de représenter un moyen de communication idéal entre le personnel médical et soignant et le monde de la gestion. Comme nous le rappelions au début de cette thèse, les concepteurs des DRGs (Fetter et Thompson) ont regretté le manque d'intérêt manifesté par les gestionnaires d'hôpitaux pour l'utilisation de leur concept dans le management hospitalier. Au terme de cette thèse, nous pensons que, si l'analyse des coûts par pathologie reste encore d'un abord difficile, elle peut rendre d'importants services en associant médecins et managers à l'élaboration d'un contrôle de gestion enfin adapté à la spécificité de leurs institutions.

Hospital information systems in China are improving and a casemix system for describing inpatient care is looking more feasible than previously. Implementing a casemix classification system for acute inpatient care in China could help to improve regional planning and hospital quality and efficiency. The purpose of this study was to evaluate the Australian DRG system as the basis for developing an acute inpatient casemix system appropriate for China. The applicability of the Australian AR-DRG system has been evaluated (in terms of homogeneity achieved and comparability of rank order) using inpatient data from Chengdu in Sichuan. Homogeneity achieved was good. The R2 value (the coefficient of multiple determination) was 0.12 for LOS and 0.17 for cost using untrimmed data and using (L3H3) trimmed data, R2 was 0.45 for LOS and 0.59 for cost. This explanatory power is comparable to other DRG classification systems although there are a few MDCs in which AR-DRGs exhibit poorer explanatory power. Rank order of groups was generally comparable. The AR-DRG system incorporates hierarchies of DRGs within groups of adjacent DRGs, within medical and surgical partitions and across all DRGs within each MDC. I have compared the ranking of DRGs based on average cost with the ranking assumed by the AR-DRG system, at the adjacent group level, within partitions and at the level of the MDC. I used the Spearman Rank Correlation coefficient to compare DRG order across partitions and whole MDCs. In general the cost relativities of the Chinese inpatient episodes grouped by the AR-DRG system correspond to the logical hierarchies assumed by the system. On this basis Chinese and Australian episodes of care within most of the MDCs appear to reflect the same broad pattern of resource consumption. Further research will be needed to determine where and how the grouping rules used in the AR-DRG system might need to be changed to more accurately reflect Chinese circumstances. For example the cost structures of Chinese health services are different from those in Australia. The Australian Refined DRGs (AR-DRGs) would provide a sound basis from which to develop a Chinese version of DRGs.

Background Hospitals in Iran have mainly been managed in a centralised system and funded historically through annual budgeting with little autonomy at hospital level. The current annual budgeting system is inequitable and is not reflective of hospital activity. Hospital resources are not distributed with regard to efficiency indicators and lobbying and political power of the managers are common issues influencing budget. Evidence suggests that hospitals in Iran will be even further challenged due to the growing and aging population. Reform of funding policy, particularly in hospitals, is now being considered as a critical step to improvement of Iran’s health system. Objectives This is a study of the theoretical and practical aspects of the implementation of casemix funding of hospitals in Iran. It aims to identify the knowledge and attitude of hospital managers and staff about the feasibility of casemix; to investigate availability, reliability and completeness of hospital discharge and financial data; to measure the appropriateness of the Australian Refined Diagnosis Related Groups (AR-DRGs); to build up a basis for further studies on casemix funding of hospitals; and, to assist the efficient use of scarce resources among and between hospital systems. Methods First, a descriptive survey, using an eleven-item questionnaire, was conducted to assess the level of knowledge and attitudes of hospital managers and key staff about casemix funding and its appropriateness. Second, patients’ clinical and demographic information were collected from the discharge system of a single study hospital, to evaluate the accuracy and completeness of these data for adopting casemix in Iran’s hospitals. This information was used to classify patient episodes into DRG classes using the LAETA Grouper and AR-DRGs. Third, DRG cost weights were calculated based on the internationally accepted principles of 'activity-based' cost accounting and cost-modelling, taking into account current realities of hospital accounting structures, availability of data, as well as time and budget constraints. To identify whether there is any association between modelled cost weights and length of stay at the DRG level, two statistical measures, the Pearson correlation coefficient and regression coefficient were calculated using the STATA statistical package. Finally, a total of 465,531 acute inpatient separations, from 35 hospitals, was used to examine the performance of AR-DRGs in the study environment. L3H3; IQR; and 10th- 95th percentile methods were used for excluding extreme cases. The coefficient of variation (CV) and reduction in variance (R2) were used to measure the degree of homogeneity achieved by the classification system and the extent to which the dispersion of lengths of stay could be explained by grouping the cases into the discrete DRG classes. Results The staff survey results showed that 75% and 58% of the participants had not ever heard of the terms casemix and DRGs, respectively. The majority of the participants described casemix and DRGs as a cost allocation and/or funding tool rather than a classification system useful for management and performance measurement. The most common barriers to casemix implementation outlined by the participants included: the lack of good foundation knowledge; difficulty in data access; and lack of or incomplete knowledge of the chief managers and staff about the casemix. The data quality study findings suggest that the accuracy and completeness of the available data in the study hospital is variable and not highly reliable. The grouper identified invalid records of principal diagnosis, age, sex, and length of stay for 4% of total separations. No complication and comorbidity effects were recorded for 93% of cases. Although general practitioners are employed as gate keepers to control coding accuracy, there is no standard quality control to secure the accuracy and consistency of coding either at the physician or coder level. Coders, except in a few cases, have not been formally trained. According to the data study, the estimation of DRG cost weights using a clinical costing approach is almost impossible due to inadequate financial and utilisation information at the patient level, poorly computerised 'feeder systems', and low quality data. In contrast, the cost modelling approach, using Australian service weights resulted in the average DRG cost weight of 2.723 million Iranian Rials (equal to US $295). A regression coefficient of 0.14 (CI = 0.12 − 0.16) suggests that the average cost weight increases by 14% for every one day increase in average length of stay. Classifying a total of 465,531 acute inpatient separations using AR-DRG resulted in 579 DRG classes. Although reduction in variance (R2) for untrimmed data was low (R2 = 0.17) for LOS, trimming by L3H3, IQR, and 10th-95th percentile method improved the value of R2 to 0.53, 0.48, and 0.51, respectively. Low values of R2 for DRGs within several MDCs such as MDC 02, 05, 10, 15, and MDC 20 were identified. Conclusion This study concludes that the implementation of the casemix funding of hospitals in the Iranian health system and in Iranian Social Security Organisation in particular, is quite feasible and that AR-DRGs would provide a useful basis for introducing casemix in the system. However, the effective implementation of casemix in Iran would depend on a number of factors including: active cooperation and contribution of hospital staff at all levels and in all departments in the implementation process and provision of reliable data; updating hospital information systems; improving the quality of costing information; adopting an appropriate classification system, and, finally, adequate scrutiny of health care providers’ behaviours through the regular assessment of hospital performance and quality of care.

Increase in the cost of medical care services has become an important issue in many countries that have implemented national health insurance, including Taiwan. On July of 2002, the National Health Insurance of Taiwan implemented a global budgeting system for all hospital payments. It was hoped that such a system would control the increase of medical expenses within a certain expected range. However, in the absence of reasonable payment bases and effective utilization management and control mechanism, the outcome of implementing this new payment system has been difficult to measure. Therefore, the National Health Insurance (NHI) studied the possibility of implementing DRGs (diagnosis related groups) for all in-patient payments. To evaluate the impact of the new payment system, the medicinal datas collected 1 year before and after implementation of TW-DRGs were analyzed. The tested target is an orthopaedic department in a Public Medical Center. The tested items including average of days in hospital, medical costs, application of National insurance, and sub-item total knee replacement (TKR) and total hip replacement (THR). For overall investigation of the tested orthopaedic department, our findings revealed that implementation of TW-DRGs significantly diminished the average of days in hospital and the average of medical costs. However, implementation of TW-DRGs showed slight influence on the National Health Insurance Application. As to investigate common surgeries, TKR and THR, only the average of days in hospital of TKR was significantly decreased by implementation of TW-DRGs. In addition, other specific TW-DRGs numbered items were also examined to determine the alteration of the factors described above. Our results showed that implementation of TW-DRGs significantly diminished the days in hospital, the medical cost, and the National Health Insurance Application for the selected TW-DRGs numbered items. However, the quality in health care didn¡¦t have significant change after implementation of TW-DRGs. More complete data pools are needed for the more precise analysis to evaluate the influence of TW-DRGs system on the management of hospital and other medical factors in Taiwan.

Le calcul des coûts des séjours et des pathologies peut être abordé selon différentes perspectives :les coûts à charge des systèmes sociaux, des patients ou des hôpitaux. La thèse est centrée sur cette dernière approche.<p>Les DRGs représentent la tentative la plus récente de maîtriser la croissance des dépenses des hôpitaux en introduisant une médicalisation partielle des mécanismes de financement.<p>La connaissance des coûts des pathologies peut permettre aux hôpitaux de participer à l’élaboration des tarifs par pathologie en faisant partie d’un échantillon de référence des coûts hospitaliers. En cas de financement basé sur les pathologies, les hôpitaux doivent pouvoir comparer le coût des séjours au chiffre d’affaires octroyé et s’y adapter. Cet intérêt s’accroît en cas de financement forfaitaire, évolution qui semble se profiler en Belgique tout comme dans d’autres pays. En décrivant une méthodologie de calcul des coûts par pathologie et en indiquant la manière dont ceux-ci pourraient contribuer à la création d’une échelle de cost-weights, notre thèse incite les hôpitaux à adopter une politique proactive dans le domaine du financement des hôpitaux. <p>Les comparaisons de coûts hospitaliers pour évaluer la gestion sont pratiquées depuis de nombreuses années. Cependant, ce « benchmarking » est imparfait car il ne prend pas en compte la lourdeur des patients pris en charge. La standardisation des coûts sur base du case-mix de l’hôpital suppose un préalable important :l’existence d’une échelle de cost-weights issue d’un échantillon représentatif d’hôpitaux. Si cette situation n’est pas encore totalement rencontrée en Belgique, il est néanmoins possible de suggérer une voie de réflexion. La simulation inspirée de la méthodologie suisse à partir d’un échantillon de quatre hôpitaux belges présentée dans le cadre de cette thèse, est une première avancée en ce sens. <p>Un des problèmes majeurs de la gestion hospitalière est d’intéresser les prescripteurs et les prestataires à un contrôle de gestion essentiellement financier. Depuis quelques années, de nombreux efforts visent à intégrer de nouveaux indicateurs de performance dans les tableaux de bord. L’analyse des coûts des pathologies et de la variabilité des cas permet d’entamer un dialogue entre gestionnaire et corps médical. En abordant différentes études (apport des nomenclatures dans le calcul des coûts par pathologie, mesure des coûts associés aux bactériémies nosocomiales, analyse des facteurs médico-sociaux expliquant les surcoûts des patients outliers, analyse de la relation entre le coût et la sévérité des cas, comparaison des coûts de production et des pratiques médicales), nous avons voulu montrer l’importance d’associer une approche médicalisée à des raisonnements économiques. Si elle se développe, cette approche est susceptible de représenter un moyen de communication idéal entre le personnel médical et soignant et le monde de la gestion. <p>Comme nous le rappelions au début de cette thèse, les concepteurs des DRGs (Fetter et Thompson) ont regretté le manque d'intérêt manifesté par les gestionnaires d'hôpitaux pour l'utilisation de leur concept dans le management hospitalier. Au terme de cette thèse, nous pensons que, si l'analyse des coûts par pathologie reste encore d'un abord difficile, elle peut rendre d'importants services en associant médecins et managers à l'élaboration d'un contrôle de gestion enfin adapté à la spécificité de leurs institutions.<p> / Doctorat en Sciences de la santé publique / info:eu-repo/semantics/nonPublished