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Study Design: Level 3 retrospective database study., Objective: This study aims to compare work RVU (wRVU), practice expense RVU (peRVU), malpractice RVU (mpRVU), and inflation-adjusted facility price alongside MS-DRG relative weight length of stay (LOS) for cervical spine fusions between 2011 and 2023., Summary of Background Data: Both RVU and MS-DRG reimbursement have been studied in various surgical subspecialties; however, little investigation has centered on cervical spine fusions. To the best of our knowledge, this is the first study to investigate trends in RVU and MS-DRG reimbursement in cervical spine fusion throughout the COVID-19 pandemic., Methods: Center for Medicaid and Medicare Services (CMS) physician fee schedule was queried between 2011 and 2023 for RVU and facility reimbursement using common single and multilevel anterior and posterior cervical fusion codes. RVU facility prices were inflation adjusted to 2023. MS-DRG reimbursement data from 2011 to 2022 were compiled for cervical spinal fusion procedures with major complication or comorbidity (MCC) 471, complication or comorbidity (CC) 472, and without CC/MCC 473. Compound annual growth rates (CAGRs), Mean Annual Change, and yearly percent changes were calculated., Results: No changes in wRVU were seen for all cervical CPT codes; however, the CAGR of peRVU (-0.51%±0.60%) and mpRVU (0.69%±0.41%) demonstrated marginal fluctuations. Every CPT code displayed an inflation-adjusted facility price decrease (-2.18%±0.24%). When assessing MS-DRG, there were marginal changes in geometric mean LOS (0.17%±0.45%), arithmetic mean LOS (-0.15%±0.84%), and relative weight (1.09%±0.68%). Unlike RVU reimbursement, the yearly percent change differs between each MS-DRG code., Conclusions: Inflation-adjusted RVU reimbursement facility prices demonstrated a consistent decrease, while DRG code reimbursement stayed relatively consistent over the study period. This data may help surgeons and hospitals become cognizant of temporal variations in reimbursement patterns as it may affect their personal practice., Level of Evidence: Level III retrospective study., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Diagnosis-related groups (DRGs) is a patient classification system used to characterize the types of patients that the hospital manages and to compare the resources needed during hospitalization. The DRG classification is based on International Classification of Diseases diagnoses, procedures, demographics, discharge status, and complications or comorbidities and compares hospital resources and outcomes used to determine how much Medicare pays the hospital for each "product/medical condition." The All-Patient Refined DRG (APR-DRG) incorporated severity of illness (SOI) and risk of mortality (ROM) into the DRG system to adjust for patient complexity to compare resource utilization, complication rates, and lengths of stay., Methods: This study included 18,478 adult patients admitted to a tertiary care center in Lubbock, Texas during a 1-year period. We recorded the APR-DRG SOI and ROM and some clinical information on these patients, including age, sex, admission shock index, admission glucose and lactate levels, diagnoses based on International Classification of Diseases, Tenth Revision discharge coding, length of stay, and mortality. We compared the levels of SOI and ROM across this clinical information., Results: As the levels of SOI and ROM increase (which indicates increased disease severity and risk of mortality), age, glucose levels, lactate levels, shock index, length of stay, and mortality increased significantly ( P < 0.001). Multiple logistic regression analysis demonstrated that each unit increase in ROM and SOI level was significantly associated with an 11.45 and a 10.37 times increase in the odds of in-hospital mortality, respectively. The C-statistics for the corresponding models are 0.947 and 0.929, respectively. When both ROM and SOI were included in the model, the magnitudes of increase in odds of in-hospital mortality were 5.61 and 1.17 times for ROM and SOI, respectively. The C-statistic is 0.949., Conclusions: This study indicates that the APR-DRG SOI and ROM scores provide a classification system that is associated with mortality and correlates with other clinical variables, such as the shock index and lactate levels, which are available on admission.

Importance: Hospitals are reimbursed based on Diagnosis Related Groups (DRGs), which are defined, in part, by patients having 1 or more complications or comorbidities within a given DRG family. Hospitals have made substantial investment in efforts to document these complications and comorbidities., Objective: To examine temporal trends in DRGs with a major complication or comorbidity, compare these findings with 2 alternative measures of disease severity, and estimate associated changes in payment., Design, Setting, and Participants: This retrospective cohort study used data from the all-payer National Inpatient Sample for admissions assigned to 1 of the top 20 reimbursed DRG families at US acute care hospitals from January 1, 2012, to December 31, 2016. Data were analyzed from July 10, 2018, to May 29, 2019., Exposures: Quarter year of hospitalization., Main Outcomes and Measures: The primary outcome was the proportion of DRGs with a major complication or comorbidity. Secondary outcomes were comorbidity scores, risk-adjusted mortality rates, and estimated payment. Changes in assigned DRGs, comorbidity scores, and risk-adjusted mortality rates were analyzed by linear regression. Payment changes were estimated for each DRG by calculating the Centers for Medicare & Medicaid Services weighted payment using 2012 and 2016 case mix and hospitalization counts., Results: Between 2012 and 2016, there were 62 167 976 hospitalizations for the 20 highest-reimbursed DRG families; the sample was 32.9% male and 66.8% White, with a median age of 57 years (interquartile range, 31-73 years). Within 15 of these DRG families (75%), the proportion of DRGs with a major complication or comorbidity increased significantly over time. Over the same period, comorbidity scores were largely stable, with a decrease in 6 DRG families (30%), no change in 10 (50%), and an increase in 4 (20%). Among 19 DRG families with a calculable mortality rate, the risk-adjusted mortality rate significantly decreased in 8 (42%), did not change in 9 (47%), and increased in 2 (11%). The observed DRG shifts were associated with at least $1.2 billion in increased payment., Conclusions and Relevance: In this cohort study, between 2012 and 2016, the proportion of admissions assigned to a DRG with major complication or comorbidity increased for 15 of the top 20 reimbursed DRG families. This change was not accompanied by commensurate increases in disease severity but was associated with increased payment.

Template matching is a proposed approach for hospital benchmarking, which measures performance based on matching a subset of comparable patient hospitalizations from each hospital. We assessed the ability to create the required matched samples and thus the feasibility of template matching to benchmark hospital performance in a diverse healthcare system.Nationwide Veterans Affairs (VA) hospitals, 2017.Observational cohort study.We used administrative and clinical data from 668,592 hospitalizations at 134 VA hospitals in 2017. A standardized template of 300 hospitalizations was selected, and then 300 hospitalizations were matched to the template from each hospital.There was substantial case-mix variation across VA hospitals, which persisted after excluding small hospitals, hospitals with primarily psychiatric admissions, and hospitalizations for rare diagnoses. Median age ranged from 57 to 75 years across hospitals; percent surgical admissions ranged from 0.0% to 21.0%; percent of admissions through the emergency department, 0.1% to 98.7%; and percent Hispanic patients, 0.2% to 93.3%. Characteristics for which there was substantial variation across hospitals could not be balanced with any matching algorithm tested. Although most other variables could be balanced, we were unable to identify a matching algorithm that balanced more than ∼20 variables simultaneously.We were unable to identify a template matching approach that could balance hospitals on all measured characteristics potentially important to benchmarking. Given the magnitude of case-mix variation across VA hospitals, a single template is likely not feasible for general hospital benchmarking.

Purpose: Mortality in burn intensive care unit (ICU) has been decreasing and treatment appears to be changing. The aims of this study: (1) examine outcome in burn patients, (2) examine changes in ICU indication and (3) explore the influence of a changing case-mix., Methods: Retrospective study in patients admitted to ICU (1987-2016). Four groups were specified: major burns (≥15% TBSA), inhalation injury with small injury (<15% TBSA, inhalation injury), watchful waiting (<15% TBSA, without inhalation injury), tender loving care (patients withheld from treatment). Logistic regression was performed to evaluate the relation between case-mix and outcome., Results: Overall mortality decreased to 7%. Mortality of major burns decreased by 15%. The major burn group decreased by 36%. The inhalation injury and watchful waiting group increased by 9% and 21%. The percentage of ventilated patients increased by 14% in the major burn group. 40% of patients were ventilated in the watchful waiting group., Conclusions: After correction for case-mix, survival improved, mainly in the major burn group. Case-mix shifted towards inhalation injury and watchful waiting. Growth of the watchful waiting group is not necessarily harmful. However, the increase of mechanical ventilation could be. We suggest raising awareness for risks and consequences of mechanical ventilation., (Copyright © 2019 Elsevier Ltd and ISBI. All rights reserved.)

The Medicare Severity Diagnosis Related Group (MS-DRG) weight, as derived from the MS-DRG assigned at discharge, is in part determined by the physician-documented diagnoses. However, the terminology associated with MS-DRG determination is often not aligned with typical physician language, leading to inaccurate coding and decreased hospital reimbursements. The goal of this study was to evaluate the impact of a diagnosis picklist within a paper-based history and physical examination (H&P) on the average MS-DRG weight and the Case-mix index (CMI). Our trauma center implemented a paper H&P form for trauma patients featuring picklist diagnoses aligned with the MS-DRG terminology and arranged by the physiologic system. To evaluate its impact, we conducted a cohort study using data from our trauma registry between July 2015 and November 2017. Our cohort included 442 (26.0%) paper and 1,261 (74.0%) dictated H&Ps. Average CMI (2.56 vs 2.15) and expected patients ($25,057 vs $19,825) were higher for the paper group ( P < 0.001, P = 0.002). Adjusted regression models demonstrated paper coding to be associated with 0.265 CMI points, translating to an average increase in expected payment of 6.5 per cent per patient. Utilization of a standardized, paper-based H&P template with picklist diagnoses was associated with a higher trauma service CMI and higher expected payments. Preprinted diagnoses that align with the MS-DRG terminology lead to clinical documentation improvement.

Background: The provision of emergency general surgery services is a global issue, with important implications for patients and workforce. The aim of this study was to analyze the characteristics of emergency general surgical patients in the United Kingdom, with reference to diagnostic case mix, operative workload, comorbidity, discharge destination, and outcomes, to facilitate comparisons and future service development., Methods: This is a cross-sectional population-based study based in the National Health Service in Scotland, one of the home nations of the United Kingdom. All patients aged 16 or older admitted under the care of a general surgeon, as an emergency, to a National Health Service hospital in Scotland, in 2016, were included., Results: There were 81,446 emergency general surgery admissions by 66,498 patients. Median episode age was 53 years. There were more female patients than male (55% vs 45%, p < 0.0001). The most common diagnoses were nonspecific abdominal pain (20.2%), cholecystitis (7.2%), constipation (3.4%), pancreatitis (3.1%), diverticular disease (3.1%), and appendicitis (3.1%). Only 25% of patients had operations (n = 20,292). The most frequent procedures were appendicectomy (13.1%), endoscopy (11.3%), and drainage of skin lesions (9.7%). Diagnoses and operations differed with age. Overall median length of stay was 1 day. With a 6-month follow-up, patients older than 75 years had a 19.8% mortality rate., Conclusions: Emergency general surgery in the United Kingdom is a high-volume, diagnostically diverse, and low-operative volume specialty with high short-term mortality rate in elderly patients. Consideration should be given to alternative service delivery models, which make better use of surgeons' skills while also ensuring optimal care for patients who are increasingly elderly and have complex chronic health problems., Level of Evidence: Epidemiologic study, level III.

Background: Hospitals face financial pressure from decreased margins from Medicare and Medicaid and lower reimbursement from consolidating insurers., Objectives: The objectives of this study are to determine whether hospitals that became more profitable increased revenues or decreased costs more and to examine characteristics associated with improved financial performance over time., Design: The design of this study is retrospective analyses of U.S. non-federal acute care hospitals between 2003 and 2013., Subjects: There are 2824 hospitals as subjects of this study., Main Measures: The main measures of this study are the change in clinical operating margin, change in revenues per bed, and change in expenses per bed between 2003 and 2013., Key Results: Hospitals that became more profitable had a larger magnitude of increases in revenue per bed (about $113,000 per year [95% confidence interval: $93,132 to $133,401]) than of decreases in costs per bed (about - $10,000 per year [95% confidence interval: - $28,956 to $9617]), largely driven by higher non-Medicare reimbursement. Hospitals that improved their margins were larger or joined a hospital system. Not-for-profit status was associated with increases in operating margin, while rural status and having a larger share of Medicare patients were associated with decreases in operating margin. There was no association between improved hospital profitability and changes in diagnosis related group weight, in number of profitable services, or in payer mix. Hospitals that became more profitable were more likely to increase their admissions per bed per year., Conclusions: Differential price increases have led to improved margins for some hospitals over time. Where significant price increases are not possible, hospitals will have to become more efficient to maintain profitability.

Background: Hospital costs and cost drivers in palliative care are poorly analysed. It remains unknown whether current German Diagnosis-Related Groups, mainly relying on main diagnosis or procedure, reproduce costs adequately. The aim of this study was therefore to analyse costs and reimbursement for inpatient palliative care and to identify relevant cost drivers., Methods: Two-center, standardised micro-costing approach with patient-level cost calculations and analysis of the reimbursement situation for patients receiving palliative care at two German hospitals (7/2012-12/2013). Data were analysed for the total group receiving hospital care covering, but not exclusively, palliative care (group A) and the subgroup receiving palliative care only (group B). Patient and care characteristics predictive of inpatient costs of palliative care were derived by generalised linear models and investigated by classification and regression tree analysis., Results: Between 7/2012 and 12/2013, 2151 patients received care in the two hospitals including, but not exclusively, on the PCUs (group A). In 2013, 784 patients received care on the two PCUs only (group B). Mean total costs per case were € 7392 (SD 7897) (group A) and € 5763 (SD 3664) (group B), mean total reimbursement per case € 5155 (SD 6347) (group A) and € 4278 (SD 2194) (group B). For group A/B on the ward, 58%/67% of the overall costs and 48%/53%, 65%/82% and 64%/72% of costs for nursing, physicians and infrastructure were reimbursed, respectively. Main diagnosis did not significantly influence costs. However, duration of palliative care and total length of stay were (related to the cost calculation method) identified as significant cost drivers., Conclusions: Related to the cost calculation method, total length of stay and duration of palliative care were identified as significant cost drivers. In contrast, main diagnosis did not reflect costs. In addition, results show that reimbursement within the German Diagnosis-Related Groups system does not reproduce the costs adequately, but causes a financing gap for inpatient palliative care.

Background: Marked volume growth of inpatient treatments for spinal disease has been observed since diagnosis related groups (DRG) were introduced as payment for inpatient services in Germany. This study aims to analyse this increase by population and stratified by types of treatment., Material and Methods: Using German nationwide hospital discharge data (DRG statistics), inpatient treatments for spinal disease with or without surgery were identified. Trends in case numbers were analysed from 2005 to 2014 with consideration of demographic changes, in order to explore which age groups and which types of treatment are affected by volume growth., Results: In 2014 (2005), 289 000 (177 000) inpatient treatments with surgery and 463 000 (287 000) treatments without surgery were identified. After adjusting for demographic factors, treatments with and without surgery exhibited a relative volume growth of + 50%. This increase affected higher age groups and women, in particular. Depending on the type of treatment, very different degrees of volume growth were observed. For example, disc surgeries adjusted for demographic change increased by about + 5%, whereas spinal fusion and vertebral replacement surgeries, kypho-/vertebroplasties and decompression of the spine more than doubled. Within the non-surgically treated cases, local pain therapies of the spine increased after adjustment for demographic changes by about + 142%. The conservatively treated cases showed a demographically adjusted increase of + 22%., Conclusion: Apart from demographic changes, this analysis cannot resolve the underlying causes of volume growth in treatments for spinal disease. However, the stratified analysis of various subgroups may help to classify these developments in a more differentiated manner. The results may support a more targeted debate about potential over- or misallocation of inpatient services in this area., Competing Interests: Das Fachgebiet Strukturentwicklung und Qualitätsmanagement im Gesundheitswesen, in dem Thomas Mansky, Ulrike Nimptsch, Melissa Spoden und Claire Bolczek tätig sind, ist eine Stiftungsprofessur der Helios Kliniken GmbH., (Georg Thieme Verlag KG Stuttgart · New York.)

This article examines the question whether and how geriatrics will change in the future and whether in view of the demographic changes the trend will go more in the direction of a further expansion of geriatrics or more towards a geriatricization of individual specialist medical fields. The different development of geriatrics in the individual Federal States can only be understood historically and is absolutely problematic against the background of the new hospital remuneration system. Geriatrics is a typical cross-sectional faculty and still has demarcation problems with other faculties but has also not yet clearly defined the core competence. This certainly includes the increasing acquisition of decentralized joint treatment concepts and geriatric counselling services in the future, in addition to the classical assessment instruments. Keywords in association with this are: traumatology and othopedics of the elderly, geriatric neurology and geriatric oncology. Interdisciplinary geriatric expertise is increasingly being requested. Outpatient structures have so far not been prioritized in geriatrics. An independent research is under construction and it is gratifying that academic interest in geriatrics seems to be increasing and new professorial chairs have been established. It is not possible to imagine our hospital without geriatrics; however, there is still a certain imbalance between the clearly increased number of geriatric hospital beds, the representation of geriatrics in large hospitals (e.g. specialized and maximum care hospitals and university clinics), the secure establishment in further education regulations and the lack of a uniform nationwide concept of geriatrics.

Study Design: A retrospective observational study., Objective: The purpose of this study is to examine the variation in thoracolumbar fusion (TLF) payment and determine the drivers of this variation., Summary of Background Data: As health care spending continues to increase, variation in surgical procedures reimbursements has come under more scrutiny. TLF is an example of a high-cost, proven-benefit procedure that is often the focus of Centers for Medicare and Medicaid Services (CMS) administrators. There is a wide variation in TLF charges, but the drivers for this variation are not clear., Methods: Claims for TLF were identified in the CMS data by analyzing Diagnosis Related Group (DRG) number 460 ("Spinal Fusion Except Cervical without Major Complications or Comorbidities"). Data on factors that may impact cost of care were collected from four sources: the United States Census Bureau, CMS, the Dartmouth Atlas, and WWAMI Rural Health Research Center. These were then grouped into seven categories: quality, supply, demand, substitute treatment availability, patient characteristics, competitive factors, and provider characteristics. Predictive reimbursement models were created from the data using multivariate linear regression to understand the factors that influence TLF reimbursement., Results: There was significant geographic variability in reimbursement. The largest contribution to reimbursement variation came from variables in the demand (ΔR = 13.4%, P < 0.001), supply (ΔR = 9.2%, P < 0.001), and competitive factor domains (ΔR = 9.1%, P < 0.001). The top three drivers that increased reimbursement were provider charges (β = 0.37, P < 0.001), total Medicare reimbursement in the region (β = 0.19, P < 0.001), and the number of spinal surgeries per 1000 patients in that region (β = 0.06, P = 0.02). Institutional volume, a surrogate for quality was negatively associated with TLF reimbursement., Conclusion: There was wide variation in reimbursement for TLF across the U.S. The variables that drive TLF reimbursement variation include supply, demand, and competition. Interestingly, quality of care was not associated with increased TLF reimbursement., Level of Evidence: N/A.

A well-established political economic literature has shown as multi-level governance affects the inefficiency of public expenditures. Yet, this expectation has not been empirically tested on health expenditures. We provide a political economy interpretation of the variation in the prices of 6 obstetric DRGs using Italy as a case study. Italy offers a unique institutional setting since its 21 regional governments can decide whether to adopt the national DRG system or to adjust/waive it. We investigate whether the composition and characteristics of regional governments do matter for the average DRG level and, if so, why. To address both questions, we first use a panel fixed effects model exploiting the results of 66 elections between 2000 and 2013 (i.e., 294 obs) to estimate the link between DRGs and the composition and characteristics of regional governments. Second, we investigate these results exploiting the implementation of a budget constraint policy through a difference-in-differences framework. The incidence of physicians in the regional government explains the variation of DRGs with low technological intensity, such as normal newborn, but not of those with high technological intensity, as severely premature newborn. We also observe a decrease in the average levels of DRGs after the budget constraint implementation, but the magnitude of this decrease depends primarily on the presence of physicians among politicians and the political alignment between the regional and the national government. To understand which kind of role the relevance of the political components plays (i.e., waste vs. better defined DRGs), we check whether any of the considered political economy variables have a positive impact on the quality of regional obstetric systems finding no effect. These results are a first evidence that a system of standardized prices, such as the DRGs, is not immune to political pressures., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: We set out to compare the rates of Medicare reimbursement to physicians versus hospitals for several major vascular procedures over a period of 5 years., Methods: We queried the Wolters Kluwer MediRegs database to collect Medicare reimbursement data from fiscal years 2011 to 2015. We surveyed reimbursements for carotid endarterectomy, carotid angioplasty and stenting, femoropopliteal bypass, and lower extremity fem-pop revascularization with stenting. Based on data availability, we surveyed physician reimbursement data on the national level and in both medically overserved and underserved areas. Hospital reimbursement rates were examined on a national level and by hospitals' teaching and wage index statuses., Results: We found that for all 4 vascular procedures, Medicare reimbursements to hospitals increased by a greater percentage than to physicians. By region, underserved areas had lower physician reimbursements than the national average, while the opposite was true for overserved areas. Additionally, for hospital Medicare reimbursements, location in a high wage index accounted for a significant increase in reimbursement over the national average, with teaching status contributing to this increase in a smaller extent., Conclusions: These data on Medicare reimbursements indicate that payments to hospitals are increasing more significantly than to physicians. This disparity in pay changes affects both independent and academic vascular surgeons. Medicare should consider pay increases to independent providers in accordance to the hospital pay increase., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Resulting from health care reform in Germany that was implemented in 2003-2004, a new medical classification system called the "Diagnosis Related Groups" (DRGs) was introduced in hospitals. According to the media, social scientists, and a few physicians interviewed in this study the policy negatively transformed the German health care system by allowing the privatization of the hospital sector consistent with the neoliberal health care model. Allegedly, this privileged economic values over the quality of health care and introduced competition between hospitals. Nevertheless, members of the Hospital Liaison Committees (HLCs) of Jehovah's Witnesses argued that the DRGs system could be used to the advantage of Jehovah's Witness (JW) patients. HLCs often assist in the patient's search by providing names of physicians that would be willing to refrain from blood transfusions. This article draws from nine months of ethnographic research with Jehovah's Witnesses, including members of the HLCs, carried out primarily in Berlin between 2010 and 2012. By focusing on JWs, whose refusal of blood transfusions is often exemplified as particularly difficult for the biomedical profession, it addresses the "unintended" consequences of the introduction of DRGs into the German health care system that remain unexplored by health and social science scholarship. It argues that although JWs have long been associated with the judicialization of religious freedom globally, they do not equally engage in the judicialization of health in countries such as Germany. The reason for this is embedded not only in health care policy that favors mediation over medical malpractice litigation. It also results from the synergy of health care reforms that prioritize standardizing and economizing measures such as DRGs as well as practices implemented by Patient Blood Management programs that JW institutions, such as HLCs, have tapped into., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objective: To investigate changes in comorbidity coding after the introduction of diagnosis related groups (DRGs) based prospective payment and whether trends differ regarding specific comorbidities., Data Sources: Nationwide administrative data (DRG statistics) from German acute care hospitals from 2005 to 2012., Study Design: Observational study to analyze trends in comorbidity coding in patients hospitalized for common primary diseases and the effects on comorbidity-related risk of in-hospital death., Extraction Methods: Comorbidity coding was operationalized by Elixhauser diagnosis groups. The analyses focused on adult patients hospitalized for the primary diseases of heart failure, stroke, and pneumonia, as well as hip fracture., Principal Findings: When focusing the total frequency of diagnosis groups per record, an increase in depth of coding was observed. Between-hospital variations in depth of coding were present throughout the observation period. Specific comorbidity increases were observed in 15 of the 31 diagnosis groups, and decreases in comorbidity were observed for 11 groups. In patients hospitalized for heart failure, shifts of comorbidity-related risk of in-hospital death occurred in nine diagnosis groups, in which eight groups were directed toward the null., Conclusions: Comorbidity-adjusted outcomes in longitudinal administrative data analyses may be biased by nonconstant risk over time, changes in completeness of coding, and between-hospital variations in coding. Accounting for such issues is important when the respective observation period coincides with changes in the reimbursement system or other conditions that are likely to alter clinical coding practice., (© Health Research and Educational Trust.)

Hospital financing 2016 will be influenced by the prospects of the approaching considerable changes. It is assumed that the following years will lead to a considerable reallocation of financial resources between hospitals. While not directly targeted by new regulations, reallocations always also affect specialties like rheumatology. Compared to the alterations in the legislative framework the financial effects of the yearly adaptation of the German diagnosis-related groups system are subordinate. Only by comprehensive consideration of current and expected changes a forward-looking and sustainable strategy can be developed. The following article presents the relevant changes and discusses the consequences for hospitals specialized in rheumatology.

To understand the complex system of reimbursement for health care services, it is helpful to have a working knowledge of the historic context of diagnosis-related groups (DRGs), as well as their utility and increasing relevance. Congress implemented the DRG system in 1983 in response to rapidly increasing health care costs. The DRG system was designed to control hospital reimbursements by replacing retrospective payments with prospective payments for hospital charges. This article explains how these payments are calculated. Every inpatient admission is classified into one of several hundred DRGs that are based on the diagnosis, complications, and comorbidities. The Centers for Medicare & Medicaid Services (CMS) assigns each DRG a weight that the CMS uses in conjunction with hospital-specific data to determine reimbursement. A population's DRGs represent the resources needed to treat the medical disorders of that population. Hospital administrators use this information to budget and plan for the future. The Affordable Care Act and other recent legislation affect medical reimbursement by altering the DRG system. Radiologic procedures in particular are affected. This legislation will give DRGs an even larger role in determining reimbursements in the coming years., (© RSNA, 2015.)

The announced major reforms will most probably not have an impact on hospital financing before 2016. Nevertheless, the numerous minor changes in the legislative framework and the new version of the German diagnosis-related groups (G-DRG) system can be important for hospitals specialized in rheumatology. The following article presents the relevant changes and discusses the consequences for hospitals specialized in rheumatology.

Providers that care for disproportionate numbers of disadvantaged patients tend to perform less well than other providers on quality measures commonly used in pay-for-performance programs. This can lead to the undesired effect of redistributing resources away from providers that most need them to improve care. We present a new pay-for-performance scheme that retains the motivational aspects of standard incentive designs while avoiding undesired effects. We tested an alternative incentive payment approach that started with a standard incentive payment allocation but then "post-adjusted" provider payments using predefined patient or provider characteristics. We evaluated whether such an approach would mitigate the negative effects of redistributions of payments across provider organizations in California with disparate patient populations. The post-adjustment approach nearly doubled payments to disadvantaged provider organizations and greatly reduced payment differentials across provider organizations according to patients' income, race/ethnicity, and region. The post-adjustment of payments could be a useful supplement to paying for improvement, aligning the goals of disparity reduction and quality improvement., (Project HOPE—The People-to-People Health Foundation, Inc.)

The patient-centered medical home model of primary care has received considerable attention for its potential to improve outcomes and reduce health care costs. Yet little information exists about the model's ability to achieve these goals for Medicaid patients. We sought to evaluate the effect of patient-centered medical home certification of Louisiana primary care clinics on the quality and cost of care over time for a Medicaid population. We used a quasi-experimental pre-post design with a matched control group to assess the effect of medical home certification on outcomes. We found no impact on acute care use and modest support for reduced costs and primary care use among medical homes serving higher proportions of chronically ill patients. These findings provide preliminary results related to the ability of the patient-centered medical home model to improve outcomes for Medicaid beneficiaries. The findings support a case-mix-adjusted payment policy for medical homes going forward., (Project HOPE—The People-to-People Health Foundation, Inc.)

Background and Purpose: Case mix adjustment is required to allow valid comparison of outcomes across care providers. However, there is a lack of externally validated models suitable for use in unselected stroke admissions. We therefore aimed to develop and externally validate prediction models to enable comparison of 30-day post-stroke mortality outcomes using routine clinical data., Methods: Models were derived (n=9000 patients) and internally validated (n=18 169 patients) using data from the Sentinel Stroke National Audit Program, the national register of acute stroke in England and Wales. External validation (n=1470 patients) was performed in the South London Stroke Register, a population-based longitudinal study. Models were fitted using general estimating equations. Discrimination and calibration were assessed using receiver operating characteristic curve analysis and correlation plots., Results: Two final models were derived. Model A included age (<60, 60-69, 70-79, 80-89, and ≥90 years), National Institutes of Health Stroke Severity Score (NIHSS) on admission, presence of atrial fibrillation on admission, and stroke type (ischemic versus primary intracerebral hemorrhage). Model B was similar but included only the consciousness component of the NIHSS in place of the full NIHSS. Both models showed excellent discrimination and calibration in internal and external validation. The c-statistics in external validation were 0.87 (95% confidence interval, 0.84-0.89) and 0.86 (95% confidence interval, 0.83-0.89) for models A and B, respectively., Conclusions: We have derived and externally validated 2 models to predict mortality in unselected patients with acute stroke using commonly collected clinical variables. In settings where the ability to record the full NIHSS on admission is limited, the level of consciousness component of the NIHSS provides a good approximation of the full NIHSS for mortality prediction., (© 2014 American Heart Association, Inc.)

Background: Since 2004 the German diagnosis-related groups (DRG) system has been applied nationwide in all German somatic hospitals. The G-DRG system is updated annually in order to increase the quality of case allocation. What developments have occurred since 2004 from the perspective of orthopedics and trauma surgery? This article takes stock of the developments between 2004 and 2014., Methods: Analysis of relevant diagnoses, medical procedures and G-DRGs in the versions 2004 and 2014 based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI)., Results: The number of G-DRGs in the whole system increased by 45.1 % between 2004 and 2014. The number of G-DRGs in the major diagnostic category (MDC) 08 that contains the majority of orthopedic and trauma surgery categories increased in the same period by 61.6 %. The reduction of variance of inlier costs in the MDC 08 category, a statistical measure of the performance of the G-DRG system, was below the corresponding value of the total system in 2004 as well in 2014. However, the reduction of variance of inlier costs in MDC 08 (+ 30.0 %) rose more from 2004 to 2014 than the corresponding value of the overall system (+ 21.5 %)., Conclusion: Many modifications of the classification systems of diagnoses (ICD-10-GM) and medical procedures (OPS) and the structures of the G-DRG system could significantly improve the quality of case allocation from the perspective of orthopedics and trauma surgery between 2004 and 2014. Th assignment of cases could be differentiated so that complex cases with more utilization of resources were allocated to higher rated G-DRGs and vice versa. However, further improvements of the G-DRG system are necessary. Only correct and complete documentation and coding can provide a high quality of calculation of costs as a basis for a correct case allocation in future G-DRG systems.

Background: The aim of this study was to determine factors associated with deviation in length of hospital stay (LOS) from that determined by diagnosis-related groups., Methods: A cohort study from a prospectively collected database was conducted, including consecutive patients undergoing surgery in a high-volume colorectal surgery department in 2009., Results: For 1,461 included patients, average expected and actual LOS were 8.17 days (interquartile range, 4.7 to 11.9 days) and 8.31 days (interquartile range, 4 to 10 days), respectively. The most prominent factors associated with an increase of LOS from expected were parenteral nutrition (5.11 days), emergency room admittance (3.67 days), and ileus (3.45 days) (P ≤ .001 for all). Other independently associated factors included blood transfusion, anastomotic leak, sepsis, pulmonary embolism, and surgeon. Patients with higher severity illness indexes and longer postoperative intensive care stay had lower than expected LOS., Conclusions: After colorectal surgery, several modifiable factors are associated with deviation of LOS from expected. An opportunity hence exists to reduce both LOS and financial burden for hospitals in an era of pay for performance., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to investigate the differences in hospitalizations between different industries in the Finnish working-age population between 1976 and 2010., Methods: Participants (n = 3,769,355) were randomly selected from seven independent consecutive national cohorts in the Statistics Finland population database, each representing a 25% sample of the working-age (18-65-year-old) population. These data were linked with diagnosis-specific records on hospitalizations, drawn from the National Hospital Discharge Registry (mean follow-up time per cohort was 4.1 years) using personal identification numbers., Results: Sociodemographics-adjusted models showed differences between the proportional hazard ratios of employment industries in all-cause hospitalization. These differences remained fairly stable (hazard ratio [HR], 0.95-1.24) throughout the 35-year period. The differences between industries varied the most in hospitalizations for mental disorders. These differences were substantial during 1976 to 1980 (HR, 1.16-2.29), decreased considerably and remained moderate between 1981 and 2000 (HR, 0.92-1.64), and then increased notably between 2001 and 2010 (HR, 1.09-2.34)., Conclusions: The cause-specific hospitalizations of different employment industries have varied, but the differences in all-cause hospitalizations have remained fairly stable, with the ranking among industries remaining almost the same over the past 35 years., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: In 2003 the German diagnosis-related groups (G-DRG) were introduced for reimbursement of inpatient treatment. The aim of this study was to analyze the development of G-DRGs in ophthalmology in Germany (MDC02) from 2004 to 2012 by means of data from the Institute for the Reimbursement System in Hospitals (InEK)., Methods: The data regarding costs, cost weighting and mean length of stay (LOS) from the G-DRG reports of the InEK from 2004 to 2012 in 9 representative surgical and non-surgical ophthalmological treatment case groups were analyzed. Differences in the coding system as well as alterations between the G-DRGs over the course of time were taken into consideration. The cost weightings were calculated taking the year 2004 as the baseline and are presented in the form of graphs., Results: The selected cases cover 54% of all G-DRG cases used by the InEK for G-DRG calculations. For 6 out of the 9 case groups there was a cost/reimbursement reduction by nearly one third of the calculated costs by InEK from 2004 to 2012. Only one case group showed an increase in costs by 23% which can be explained by alterations in graft costs in this case group. The mean LOS decreased over the time period in the 9 groups investigated by up to 40% and on average by -22.3%., Conclusions: The annually calculated costs of the InEK directly influence the calculation of the cost weightings and reimbursement and are therefore important for every hospital. During the time period analyzed a high reduction in costs and LOS in the majority of the analyzed case groups were found.

Background: Geriatric medicine, as a specialized form of treatment for the elderly, is gaining in importance due to demographic changes. Especially important for geriatric medicine is combining acute care with the need to maintain functionality and participation. This includes prevention of dependency on structured care or chronic disability and handicap by means of rehabilitation., Methods and Materials: Ten years ago, the German DRG system tried to incorporate procedures (e.g., "early rehabilitation in geriatric medicine") in the hospital reimbursement system. OPS 8-550.x, defined by structural quality, days of treatment, and number of therapeutic interventions, triggers 17 different geriatric DRGs, covering most of the fields of medicine. OPS 8-550.x had been revised continuously to give a clear structure to quality aspects of geriatric procedures. However, OPS 8-550.x is based on proven need of in-hospital treatment. In the last 10 years, no such definition has been produced taking aspects of the German hospital system into account as well as aspects of transparency and benefit in everyday work., Results: The German DRG system covers just basic reimbursement aspects of geriatric medicine quite well; however, a practicable and patient-oriented definition of "hospital necessity" is still lacking, but is absolutely essential for proper compensation. A further problem concerning geriatric medicine reimbursement in the DRG system is due to the different structures of providing geriatric in-hospital care throughout Germany.

Introduction: Increasing attention is being focused on reigning in escalating costs of healthcare, i.e. trying to 'bend the cost curve'. In gastroenterology (GI), inpatient hospital care represents a major component of overall costs. This study aimed to characterize the trend in cost of care for GI-related hospitalizations in recent years and to identify the most costly diagnostic groups., Methods: All hospital inpatients admitted between January 2008 and December 2009 with a primary diagnosis of one of the six most common GI-related Diagnosis Related Groups (DRGs) in this hospital system were identified; all DRGs contained at least 40 patients during the study period. Patient Level Costing (PLC) was used to express the total cost of hospital care for each patient; PLC comprised a weighted daily bed cost plus cost of all medical services provided (e.g., radiology, pathology tests) calculated according to an activity-based costing approach; cost of medications were excluded. All costs were discounted to 2009 values. Mean length of stay (LOS) was also calculated for each DRG., Results: Over 2 years, 470 patients were admitted with one of the six most common GI DRGs. Mean cost of care increased from 2008 to 2009 for all six DRGs with the steepest increases seen in 'GI hemorrhage (non-complex)' (31 % increase) and 'Cirrhosis/Alcoholic hepatitis (non-complex)' (45 % increase). No differences in readmission rates were observed over time. There was a strong correlation between year-to-year change in costs and change in mean LOS, r = 0.93., Conclusion: The cost of GI-related inpatient care appears to be increasing in recent years with the steepest increases observed in non-complex GI hemorrhage and non-complex Cirrhosis/Alcoholic hepatitis. Efforts to control the increasing costs should focus on these diagnostic categories.

In October 2014, the United States will switch from using the ICD-9 coding system to ICD-10. This change will allow for greater specificity in describing medical conditions and the addition of new codes as medical knowledge and technology evolve. The change will be a big one for hospitals and clinics. This article describes what physicians need to know about the new system and what the organizations they work for need to consider when preparing for the change.

The introduction of the DRG (diagnosis-related groups) system as basis for reimbursement in the German health-care system has led to a mentality of quality orientation and verification of therapeutic results. An immediate result was the formation of medical "centres" on rather different levels and consequently the inauguration of institutions, authorities, and organisations to review these centres. Finally, a range of certifications was installed in order to stratify the rather diverse aims of different centres. This review critically evaluates the current situation in the field of general and abdominal surgery in Germany., (© Georg Thieme Verlag KG Stuttgart · New York.)

In an era of economic crisis in Greece and with many uninsured citizens, the Troika (lenders of Greece) suggests reforms and promotes the internal market, resulting in a public-private system becoming more privatized. This article contradicts these proposals and attempts to suggest the necessary reforms to achieve equity of access for all and to promote efficiency, taking into account the existing needs of the population and the recession of the Greek economy.

Background: There is, globally, an often observed inequality in the health services available in urban and rural areas. One strategy to overcome the inequality is to require urban doctors to spend time in rural hospitals. This approach was adopted by the Beijing Municipality (population of 20.19 million) to improve rural health services, but the approach has never been systematically evaluated., Methods: Drawing upon 1.6 million cases from 24 participating hospitals in Beijing (13 urban and 11 rural hospitals) from before and after the implementation of the policy, changes in the rural-urban hospital performance gap were examined. Hospital performance was assessed using changes in six indices over-time: Diagnosis Related Groups quantity, case-mix index (CMI), cost expenditure index (CEI), time expenditure index (TEI), and mortality rates of low- and high-risk diseases., Results: Significant reductions in rural-urban gaps were observed in DRGs quantity and mortality rates for both high- and low-risk diseases. These results signify improvements of rural hospitals in terms of medical safety, and capacity to treat emergency cases and more diverse illnesses. No changes in the rural-urban gap in CMI were observed. Post-implementation, cost and time efficiencies worsened for the rural hospitals but improved for urban hospitals, leading to a widening rural-urban gap in hospital efficiency., Conclusions: The strategy for reducing urban-rural gaps in health services adopted, by the Beijing Municipality shows some promise. Gains were not consistent, however, across all performance indicators, and further improvements will need to be tried and evaluated.

Background: Due to demographics, characteristic multimorbidity in geriatric patients is resulting in increased social, medical, and healthcare challenges. Geriatric multimorbidity (GM) can be defined as the simultaneous occurrence of at least two diseases that require medical care with an interdisciplinary focus on independence in activities of daily living. Typical conditions of GM are, e.g., incontinence, cognitive impairment, frailty, and decubitus., Material and Methods: Part 2 of this study is based on claims data of 240,502 AOK insurants (AOK is one of the major health insurance companies of the German statutory health insurance system) aged ≥ 60 years with at least one admission to a hospital with a geriatric ward. Geriatric conditions (GCs) were ascertained in two ways: diagnoses from physicians in the ambulant care setting and diagnoses in a hospital setting in 2008. A total of 15 GC were assessed using diagnoses based on ICD-10 codes (as per suggestion from scientific geriatric societies). An insurant was defined as a person with GM, if he/she had at least two GCs., Results: The proportion of GCs in ambulant or inpatient diagnoses of 240,502 insurants varied significantly in most cases. For specific GCs, considerably higher proportions of ambulant diagnoses (e.g., pain, impairment of vision, or hearing) or for inpatient diagnoses (e.g., electrolyte or fluid metabolism disorders, malnutrition, incontinence) were identified. Only on rare occasions were small differences observed comparing the proportions of specific GCs in the diagnoses of the two different care sectors. This finding reduces considerably the accordance between the two care sectors with reference to the presence or absence of a GC for ambulant or inpatient diagnoses. The main agreement was with the non-coding of specific GCs, not with ambulant or inpatient diagnoses. Insurants with a geriatric hospital admission or certain care level (level ≥ 1) generally had higher proportions for specific GCs for inpatient and ambulant diagnoses than non-geriatric treated insurants or insurants without a certain care level. Of the geriatric treated insurants and those with certain care levels, 90% were characterized by the presence of GM for both ambulant or inpatient diagnoses. This percentage is remarkably higher than for patients who featured no geriatric treatment or had no certain care level., Conclusion: The inclusion of ambulant diagnoses in addition to inpatient diagnosis offers comprehensive possibilities to identify insurants with GM in claims data. The contribution of the diagnoses of both care sectors for the identification of GC and GM varies with regard to attribute and insurant orientation. Furthermore, significant attribute-oriented overlap of insurants claiming geriatric treatments and insurants with certain care levels became visible, which can open new possibilities for simpler identification of a portion of patients with GM.

Objectives: This report examines the comparability between the rates of inpatient procedures for persons aged 65 and over using the National Hospital Discharge Survey (NHDS) and Medicare claims data., Methods: The estimates in this report are based on data from NHDS and Medicare claims submitted by hospital providers for inpatient stays among Part A fee-for-service Medicare beneficiaries aged 65 and over. The discharge rates, selected procedures rates, and comparability ratios are reported for older men and women, by age and sex, for 1999 and 2007., Results: Between 1999 and 2007, observed decreases in discharge rates and in all-listed procedure rates derived from NHDS were not significant, while Medicare discharge rates decreased and procedure rates increased significantly. In 1999 and 2007, no statistically significant differences were found between NHDS and Medicare estimates for discharge rates in the age-sex groups examined except for those aged 85 and over. In both years, the comparability ratios between Medicare and NHDS procedure rates were significantly different from one for about 50% of selected procedures, and ranged from 1.12 to 1.26 in 1999 and from 1.16 to 1.41 in 2007. This reflects more procedures recorded in 1999 and 2007 in Medicare data per discharge. The comparability ratio was higher for most of the cardiac procedures, and in general, was closer to one when fewer procedures were performed per discharge and for procedures with lower utilization rates.

The remuneration system of German diagnosis-related groups (G-DRG) is updated every year in a clearly defined process. This article presents all changes relevant for urologists in 2012.

Background: Orthopedics and trauma surgery are subject to continuous medical advancement. The correct and performance-based case allocation by German diagnosis-related groups (G-DRG) is a major challenge. This article analyzes and assesses current developments in orthopedics and trauma surgery in the areas of coding of diagnoses and medical procedures and the development of the 2012 G-DRG system., Methods: The relevant diagnoses, medical procedures and G-DRGs in the versions 2011 and 2012 were analyzed based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI)., Results: Changes were made for the International Classification of Diseases (ICD) coding of complex cases with medical complications, the procedure coding for spinal surgery and for hand and foot surgery. The G-DRG structures were modified for endoprosthetic surgery on ankle, shoulder and elbow joints. The definition of modular structured endoprostheses was clarified., Conclusion: The G-DRG system for orthopedic and trauma surgery appears to be largely consolidated. The current phase of the evolution of the G-DRG system is primarily aimed at developing most exact descriptions and definitions of the content and mutual delimitation of operation and procedures coding (OPS). This is an essential prerequisite for a correct and performance-based case allocation in the G-DRG system.

Background: The purpose of this study was to assess whether or not the change in coding classification had an impact on diagnosis and comorbidity coding in hospital discharge data across Canadian provinces., Methods: This study examined eight years (fiscal years 1998 to 2005) of hospital records from the Hospital Person-Oriented Information database (HPOI) derived from the Canadian national Discharge Abstract Database. The average number of coded diagnoses per hospital visit was examined from 1998 to 2005 for provinces that switched from International Classifications of Disease 9(th) version (ICD-9-CM) to ICD-10-CA during this period. The average numbers of type 2 and 3 diagnoses were also described. The prevalence of the Charlson comorbidities and distribution of the Charlson score one year before and one year after ICD-10 implementation for each of the 9 provinces was examined. The prevalence of at least one of the seventeen Charlson comorbidities one year before and one year after ICD-10 implementation were described by hospital characteristics (teaching/non-teaching, urban/rural, volume of patients)., Results: Nine Canadian provinces switched from ICD-9-CM to ICD-I0-CA over a 6 year period starting in 2001. The average number of diagnoses coded per hospital visit for all code types over the study period was 2.58. After implementation of ICD-10-CA a decrease in the number of diagnoses coded was found in four provinces whereas the number of diagnoses coded in the other five provinces remained similar. The prevalence of at least one of the seventeen Charlson conditions remained relatively stable after ICD-10 was implemented, as did the distribution of the Charlson score. When stratified by hospital characteristics, the prevalence of at least one Charlson condition decreased after ICD-10-CA implementation, particularly for low volume hospitals., Conclusion: In conclusion, implementation of ICD-10-CA in Canadian provinces did not substantially change coding practices, but there was some coding variation in the average number of diagnoses per hospital visit across provinces.

Analysis of your specific business is a key component of ICD-10 implementation. An understanding of your organization's current reimbursement trends will go a long way to assessing and preparing for the impact of ICD-10 in your environment. If you cannot be prepared for each detailed scenario, remember that much of the analysis and resolution requires familiar coding, DRG analysis, and claims processing best practices. Now, they simply have the new twist of researching new codes and some new concepts. The news of a delay in the implementation compliance date, along with the release of grouper Version 29, should encourage your educational and business analysis efforts. This is a great opportunity to maintain open communication with the Centers for Medicare & Medicaid Services, Department of Health and Human Services, and Centers for Disease Control. This is also a key time to report any unusual or discrepant findings in order to provide input to the final rule.

Background: The epidemiology of acute orthopedic dislocations is poorly understood. A nationwide database provides a valuable resource for examining this issue in the Taiwanese population., Methods: A 6-year retrospective cohort study of 1,000,000 randomly-sampled beneficiaries from the year 2005 was used as the original population. Based on the hospitalized and ambulatory data, the concomitant ICD9-CM diagnosis codes and treatment codes were evaluated and classified into 8 and 3 major categories, respectively. The cases matching both inclusive criteria of dislocation-related diagnosis codes and treatment codes were defined as incident cases., Results: During 2000-2005, the estimated annual incidence (per 100,000 population) of total orthopedic dislocations in Taiwan was 42.1 (95%CI: 38.1-46.1). The major cause of these orthopedic dislocations was traffic accidents (57.4%), followed by accident falls (27.5%). The annual incidence dislocation by location was shoulder, 15.3; elbow, 7.7; wrist, 3.5; finger, 4.6; hip, 5.2; knee, 1.4; ankle, 2.0; and foot, 2.4. Approximately 16% of shoulder dislocations occurred with other concomitant fractures, compared with 17%, 53%, 16%, 76% and 52%, respectively, of dislocated elbow, wrist, hip, knee, and ankle cases. Including both simple and complex dislocated cases, the mean medical cost was US$612 for treatment of a shoulder dislocation, $504 for the elbow, $1,232 for the wrist, $1,103 for the hip, $1,888 for the knee, and $1,248 for the ankle., Conclusions: In Taiwan, three-quarters of all orthopedic dislocations were of the upper limbs. The most common complex fracture-dislocation was of the knee, followed by the wrist and the ankle. Those usually needed a treatment combined with open reduction of fractures and resulted in a higher direct medical expenditure.