 |
This Web site is a component of the SAMHSA Health Information Network. |
|
Special Report: Annotated Bibliography for
Managed Behavioral Health Care 1989-1999
Diagnosis-Related Groups (DRGs)
112. Ashcraft, M. L. F., Fries, B. E., Nerenz, D. R., et al. (1989). A psychiatric
patient classification system: An alternative to diagnostic-related groups.
Medical Care, 27, 543-555.
This article reports on a project to construct a diagnostic classification system more appropri-ate
for alcohol, drug, and mental disorders than the DRG system. The authors used data from
the Veterans Administration (VA) to construct 12 psychiatric diagnostic groupings from which
a psychiatric patient classification (PCC) system was derived. They found that this new classifi-cation
system accounts for significantly more of the variation in length of stay than the DRGs.
Moreover, they conclude that this system is more useful for hospital payment purposes because
PCCs are clinically useful. They argue that PCCs appear to be valuable candidates for inclu-sion
into the VA’s resource allocation system, and warrant exploration of its applicability to
female and non-VA populations.
Keyword: DRGs
113. Dorwart, R. A., & Chartock, L. R.(1988). Psychiatry and the resource-based
relative value scale. American Journal of Psychiatry, 145, 1237-1242.
Recent attempts to control medical costs for inpatient psychiatric services focus on regulating
hospital reimbursement through the use of DRGs. This article focuses attention on other meth-ods
to control mental health inpatient costs through regulating reimbursements received by
physicians. The authors review the resource-based relative value scale (RBRVS) as an alterna-tive
to other proposed reimbursement methods, such as physician DRGs. The RBRVS uses the
setting, time spent, difficulty in treating the patient, training, and psychiatrist’s role to deter-mine
reimbursement rates for psychiatrists. The authors suggest that the RBRVS has several
advantages over both the DRG approach and capitation and may be useful in a variety of
health care settings such as in HMOs and in the public sector.
Keyword: DRGs
114. English, J. T., Sharfstein, S. S., Scherl, D. J., Astrachan, B. M., &
Muszynski, I. L. (1988). Diagnosis-related groups and general hospital
psychiatry: The American Psychiatric Association Study. In D. J. Scherl,
J. T. English, & S. S. Sharfstein (Eds.), Prospective payment and
psychiatric care (1st ed., pp. 19-40). Washington, DC: American
Psychiatric Association.
This chapter reviews the context in which psychiatric diagnoses were exempt from the original
DRG system and reports on the findings of the Task Force on Prospective Payment, established
by the American Psychiatric Association (APA) to examine the implications of the DRG system
for psychiatry. The authors report the findings of this study which concluded that the DRG
system is not accurate or fair for psychiatric diagnoses. Based on 1.67 million Medicare cases,
the study found that there is substantial variation between hospital type in resource use by
patients within a given psychiatric DRG. For example, the mean length of stay in hospitals
with psychiatric units was 38 percent higher than that in general hospitals. The authors urge
that any system be introduced incrementally, as part of a mixed retrospective and prospective
payment approach and that levels of payment should consider the facility’s historical costs and
the diversity of treatment models.
Keyword: DRGs
115. Essock, S., & Norquist, G. S. (1988). Toward a fairer prospective
payment system. Archives of General Psychiatry, 45, 1041-1044.
An underlying assumption of the Medicare prospective payment system (PPS) is that character-istics
of patients such as diagnosis and of hospitals can be used to predict costs. The authors
challenge the assumption that the current system based on DRGs is an adequate predictor of
cost for psychiatric care. They claim that the psychiatric payment categories are poor predic-tors
of cost, accounting for between 2 percent and 15 percent of the variability in the length of
stay. They examine variables that might be added to the equations to make for a more equi-table
and effective reimbursement system for inpatient psychiatric care including additional
facility and patient characteristics. Finally, they explore incentives that can be built into a
payment system to counteract the impetus to minimize care provided.
Keyword: DRGs.
116. Freiman, M. P., Mitchell, J. B., Taube, C. A., & Harrow, B. S. (1988).
The 1985 National Institute of Mental Health/Health Care Financing
Administration study of payment for psychiatric admissions under
Medicare: Overview and a look ahead. In D. J. Scherl, J. T. English, &
S. S. Sharfstein (Eds.), Prospective payment and psychiatric care
(1st ed., pp. 91-106). Washington, DC: American Psychiatric Association.
This chapter describes a study conducted by the National Institute of Mental Health (NIMH)
and the the Centers for Medicare and Medicaid Services to examine issues relating to the classification
of alcohol, drug abuse, and mental health (ADM) admissions under prospective payment, and
the impact of modifications to this system on both exempt and nonexempt facilities. Medicareclaims in four states were used to develop "clinically related groups" (CRGs), an alternative
classification system. This system was found to perform better than the DRG system in
explaining variation in hospital costs and length of stay, but 90 percent of the variation was
still unexplained by CRGs. The use of disease staging did not help to improve predictive
power. The study also simulated DRG-related payments for ADM admissions to general hospi-tals
with and without exempt units, and found that the average simulated payment to hospitals
with exempt units was several hundred dollars higher than the average payment for an admis-sion
to a nonexempt unit. Substantial inter-state variation was found, as well as between
exempt and nonexempt hospital outlier rates. A follow-up study by the NIMH is described.
Keyword: DRGs
117. Goldman, H. H. (1988). Overview of studies on psychiatric hospital
care under a prospective payment system. In D. J. Scherl, J. T. English,
& S. S. Sharfstein (Eds.), Prospective payment and psychiatric care
(1st ed., pp. 172). Washington, DC: American Psychiatric Association.
This chapter reviews several studies examining the usefulness of case mix measures in
prospective payment. The author argues that there is no viable classification system whose
impact has been tested on the heavily differentiated mental health system. Given this, and
the fact that alternative systems may be worse than a prospective payment system (PPS), the
author urges psychiatry to play a key role in implementing an effective PPS. He argues that
psychiatry should not overemphasize the differences between health and mental health care,
as similarities are the basis for its claims for reimbursement under health insurance. An
equitable and efficient reimbursement system for mental health care can be viewed as an
opportunity for psychiatry rather than a necessary evil.
Keyword: DRGs
118. Namerow, M. J., & Gibson, R. W. (1988). Prospective payment for
private psychiatric specialty hospitals: The National Association of Private
Psychiatric Hospitals prospective payment study. In D. J. Scherl, J. T.
English, & S. S. Sharfstein (Eds.), Prospective payment and psychiatric
care, (1st ed., pp. 41-54). Washington, DC: American Psychiatric
Association.
This chapter describes a study conducted by the National Association of Private Psychiatric
Hospitals to test the adequacy of the psychiatric DRGs and alternative systems to pay hospi-tals,
and to assess the financial impact of these systems on private psychiatric specialty hospi-tals.
Thirty hospitals were randomly selected for the study, which included retrospective chart
review for patient-specific data, a questionnaire survey for hospital organization and financial
information, and site visits. Data were analyzed in order to determine the variables correlated
with length of stay and cost of care. The study found that both the original 15 DRGs and its
modified version allow for inadequate grouping for setting payment rates for private psychi-atric
hospital stays. This chapter discusses the implications of this and other findings.
Keyword: DRGs
119. Rosenheck, R., Massari, L., & Astrachan, B. M. (1990). The impact of
DRG-based budgeting on inpatient psychiatric care in Veterans
Administration medical centers. Medical Care, 28(2), 124-132.
This study examines the impact of a DRG-based resource allocation methodology (RAM) on
inpatient psychiatric care in the Veterans Administration (VA) hospitals. The authors reviewed
data on discharge for psychiatric and substance abuse disorders before and after the implemen-tation
of DRG-based budgeting in the VA system. They found a significant decline in lengths
of stay, total annual bed days per patient, and total expenditures after DRGs were instituted.
The authors conclude that RAM is a potent management tool and discuss the reasons why
these changes are attributable to this payment method and not other factors.
Keyword: DRGs
120. Ruggie, M. (1990). Retrenchment or realignment? U.S. mental health
policy and DRGs. Journal of Health Politics, Policy and Law, 15(1), 145-167.
This article examines the rise of DRGs as part of a major reorganization of the delivery of
health services in the United States. The author argues that there have been two major institu-tional
shifts in the state’s provision of mental health services; from main provider to retrospec-tive
buyer, and from retrospective payer to prospective buyer. The impact of this shift on
providers and organizations is discussed.
Keyword: DRGs
121. Sargent, S. C., Scherl, D. J., & Muszynski, I. L.(1988). The New Jersey
experience with diagnostic-related groups. In D. J. Scherl, J. T. English,
& S. S. Sharfstein (Eds.), Prospective payment and psychiatric care
(1st ed., pp. 172). Washington, DC: American Psychiatric Association.
New Jersey has long been an important laboratory for experiments with prospective reim-bursement
of hospital services. This chapter reports on a study conducted by the American
Psychiatric Association to explore the effect of the state’s DRG-based system on its psychiatric
hospitals. Interviews and focus groups with State government officials, hospital administra-tors,
and provider associations identified a number of problems with this system. Participants
were concerned that the DRG system would lead to reduction or closure of psychiatric units,
admissions based on anticipated reimbursement rather than on need, frequent utilization
review, and downgrading of staff. The authors conclude that the DRG system favors private
psychiatric hospitals which are exempt from such payment and that psychiatric DRGs
should reflect severity of illness, complications, and the costs of indigent care.
Keywords: DRGs, New Jersey
123. Zwanziger, J., Davis, L., Bamezai, A., & Hosek, S. D. (1991). Using
DRGs to pay for inpatient substance abuse services: An assessment of
the CHAMPUS reimbursement system. Medical Care, 29, 565-577.
Studies have shown that DRGs and similar classification systems poorly predict inpatient
resource use, especially mental health services. Previous studies have also demonstrated
that certain types of providers are systematically under- (or over-) reimbursed. This study
assessed how well the CHAMPUS (Civilian Health and Medical Program of the
Uniformed Services) DRG system explains variation in costs at the individual level and
predicts resource use across hospitals. The study found that substance abuse DRGs are
only partially successful in classifying CHAMPUS patients according to their resource
use, explaining only 4.2 percent of the total variance. The source of this variation might
be lack of consensus on treatment, or differences among mental health providers regard-ing
delivery of services. The study also found substantial variation in the impact of the
DRG system on hospital revenue. General hospitals were reimbursed at a higher level
than substance abuse specialty hospitals. This may reflect differences in coding practices,
or severity of patients in the two settings.
Keywords: DRGs, substance abuse
Previous | TOC | Next
|
|
