Drill Down and the Need for Change: Maternal and ... · KASUS PERSALINAN BAYI JKN tahun 2014-2017 Juta Total Persalinan 6.8 ... 7 Diseases and Disorders of the Hepatobiliary System

Drill Down and the Need for Change:Maternal and Cardiovascular System Groups

InaHea, 1 November 2018

Atik Nurwahyuni

Department of Health Policy and Administration

Faculty of Public Health, Universitas Indonesia

Definition

•Diagnosis Related Group (DRG) is a patient classification scheme which provides a clinically meaningful way of relating the number and types of patients treated in a hospital to the resources required by the hospital. (Fetter, 1991)

Data Pasien

MDC

Nervous System

Surgical Medical

MDC

Cardiovascular

Surgical

Heart Valve Procedures with Cardiac

Catheterization

Minor

Moderate

Major

Cardiac Catheterization

Minor

Moderate

Major

.....dst

Minor

Moderate

Major

Medical

Hypertension

Mild

Moderate

Severe

Heart Failure

Mild

Moderate

Severe

....dst

Mild

Moderate

Severe

....MDC 23

Surgical Medical

MDC / CMG

Surgical/Medical

Adjacent DRG/CBG

DRG/CBG

(Budi Hidayat, Atik Nurwahyuni)

3

STRUCTURE OF DRG

Frequent revisions of PCS and payment ratesCountry Patient Classification System Payment rate

Frequency of updates Time-lag to data Frequency of updates Time-lag to data

Austria Annual 2–4 years 4–5 years 2–4 years

England Annual Minor revisions annually;

irregular overhauls about every

5–6 years

Annual 3 years (but adjusted

for inflation)

Finland Annual 1 year Annual 0–1 year

France Annual 1 year Annual 2 years

Germany Annual 2 years Annual 2 years

Ireland Every 4 years Not applicable (imported

AR-DRGs)

Annual (linked to

Australian updates)

1–2 years

Netherlands Irregular Not standardized Annual or when

considered necessary

2 years, or based on

negotiations

Spain

(Catalonia)

Biennial Not applicable (imported

3-year-old CMS-DRGs)

Annual 2–3 years

Sweden Annual 1–2 years Annual 2 years

Sumber: Busse , Reinhard 2012

Model Development of In-patient Tariff in Hospital Based on INA CBG(CASE STUDY CMG O) Atik Nurwahyuni, 2015

One of the Objectives:

• To develop classification of INA-CBG CMG O based onclinical coherence and resources homogeneity

METHODOLOGY

Design

• Operational Research

Phase

First (Analyze the CBG Classification)

• Clinical classification by Expert Panel

• Medical data collection

• Cost per case analysis

Second

• Develop methodology and calculate:

• cost per CBG,

• cost weight,

• casemix,

• hospital base rate and

• tariff

Time and place

8 hospitals in DKI Jakarta and surrounding areas which represent hospital class A, B, C, D for both public and private. 2012-2015

Population and sample

All cases in CMG O

Has complete medical record

Without discharge “initiated by patient”

Total sampel 15.176

Informan

• Head of Centre for Health Financing and Health Security, Ministry of Health

• Chief of Medical doctor association

• Head of INA-CBG Team

• Expert Panel (SpOG)

R2 = 65% Untrimmed

R2 = 66% Trimmed (IQR)

No ACBG/ADRGNUMBER OF GROUPS

INA CBG AR-DRG AP-DRG STUDY

1 Cesarean Section 3 2 4 2

2 Vaginal Delivery with Sterilization, DC 3 2 1 1

3 Vaginal Delivery 3 1 2 2

4 Ectopic Pregnancy 2 1 1

5 Abortion with Procedure 3 1 1 1

6 Abortion 3 1 1 1

7 Threatened Abortion 3 1 1

8 False Labor 3 1 1 1

9 Antepartum Disease 3 1 1 2

10 Antepartum with procedure 1

11 Postpartum without Procedure 3 1 1 2

12 Postpartum with Procedure 3 2 1 1

13Vaginal Delivery with Procedure except Sterlization and DC

3 1

14 High Risk Vaginal Delivery 1

TOTAL 33 14 18 15

Example: Difference Classification between INA-CBG 4.0 and the Study

KODE ICD DESKRIPSIAdjacent CBG

INA-CBGS 4.0 STUDY

O86.0Infection of obstetric surgical

woundAntepartum Postpartum

O60.0 Preterm labor without delivery Vaginal Delivery Antepartum

O47.0False labour before 37 completed

weeks of gestation

Threatened

AbortusFalse Labor

O72.2Delayed and secondary postpartum

haemorrhageAntepartum Postpartum

O72.3 Postpartum coagulation defects Antepartum Postpartum

O73.0Retained placenta without

haemorrhageAntepartum Postpartum

O73.1Retained portions of placenta and

membranes, without haemorrhageAntepartum Postpartum

2015:

• The NCC team is

currently evaluating

the diagnoses that did

not quite fit

• Several problems in

the diagnostic code is

currently being

resolved by the

groupers

• Some problems were

resolved through a

Regulation from the

Minister of Health No.

27/2014

No Adjacent DRG N Cost (IDR)

1 Cesarean Section5.892 9.572.030

2 Vaginal Delivery with Sterilization, DC178 7.802.428

3 Vaginal Delivery4.337 3.713.734

4 Ectopic Pregnancy40 8.625.923

5 Abortion with Procedure663 4.157.953

6 Abortion104 3.587.482

7 Threatened Abortion100 2.534.726

8 False Labor116 2.658.860

9 Antepartum Disease1.373 4.427.924

10 Postpartum without Procedure148 3.442.502

11 Postpartum with Procedure87 5.279.922

Average Cost of Treatment by ADRG

Overpaid and

Underpaid

Overpaid and

Underpaid

A pregnant woman delivered the baby 4 times within a month...........

MEMBER_ID INACBG DESCRIPTION ADMISSION DISCHARGEDAYS

(READMISSION)

28443507 O-6-13-I VAGINAL DELIVERY I 25/07/2016 26/07/2016

28443507 O-6-13-I VAGINAL DELIVERY I 26/07/2016 27/07/2016 0


28443507 O-6-12-I Vaginal Delivery with Sterilization, DC 15/08/2016 16/08/2016 13

91880761 O-6-10-I CAESAREAN SECTION 20/07/2016 22/07/2016




95128705 O-6-13-I VAGINAL DELIVERY I 05/01/2016 06/01/2016




Check the Principle Diagnosis

MEMBER_IDPrimary

DxDESCRIPTION ICD X INACBG DESCRIPTION

28443507 O600 Preterm labour without delivery O-6-13-I VAGINAL DELIVERY I



28443507 O601 Preterm labour with preterm delivery O-6-12-I Vaginal Delivery with Sterilization, DC

91880761 O821 Delivery by emergency caesarean section O-6-10-I CAESAREAN SECTION

91880761 O720 Third-stage haemorrhage O-6-11-I Vaginal Delivery with Sterilization, DC

91880761 O720 Third-stage haemorrhage O-6-11-I Vaginal Delivery with Sterilization, DC

91880761 O721Other immediate postpartum haemorrhage O-6-13-I VAGINAL DELIVERY I




95128705 O800 Spontaneous vertex delivery O-6-13-I VAGINAL DELIVERY I

Slide di RDP DPR.Mari Bedah Kasus Persalinan 2014 s/d 2017: Anomali mengemuka

Do

'A K

ita

13

Estimasi klaim SC s/d 2017 Rp 13.7 Triliun, sementara persalinan normal Rp 4.9 T.

1. Apakah fenomena SID?2. Apakah “Aji Mumpung”?

PESAN: Kontrol, Audit Medis Mutlak. Syarat Active Purchaser

KASUS PERSALINAN BAYI JKN

tahun 2014-2017 Juta

Total Persalinan 6.8

Persalinan di FKTP 2.6

Persalinan di FKRTL 4.3

Persalinan SC FKRTL 2.3

% Persalinan FKRTL 62.1%

% SC thd Total Persalinan 33.5%

% SC thd Persalinan FKRTL 53.9%

% SC (Standar WHO) 10-15%

Evaluation of INA-CBG Classification:CMG I Cardiovascular System GroupsFACULTY OF PUBLIC HEALTH, UNIVERSITAS INDONESIA

14

(Budi Hidayat & Atik Nurwahyuni 2016)

Zooming CMG I Cases

15

• CMG I Case Cardiovascular System Groups are a high-cost cases

• Misclassification give significant impact to hospital and BPJSK

• The lack of cases per group, even empty, is the initial INDICATION of misclassification inthe DRGs system

Of the total 96 CBGs in CMG I, there were 6 groups whose cases were not found in the 2014 claim data. Of the cases there were 37 groups which numbered under 250 cases.

Australian Refined Diagnosis Related Group (AR-DRG) minimum case = 250 per DRG.

Methodology

16

Key steps:1. Collect and clean all the data claim INA-

CBG CMG I in 20142. Map the cases into ThaiDRG Version 5.0

Sample = all the data claim INA-CBG CMG I in 2014 (N= 329.977

cases)

• Cross-sectional design• Mixed methods: qualitative, quantitatives

and literature review

NoAdjacent

CBGDESCRIPTION N %

1 I-1-01 Heart &/or Lung Transplantation 0 0

2 I-1-02 Heart Valve Procedures with Cardiac Catheterization 0 0

3 I-1-03 Cardiothoracic Surgery for Heart Abnormality 209 0,06

4 I-1-04 Heart Valve Procedures without Cardiac Catheterization 568 0,17

5 I-1-05 Coronary Bypass Operation with Cardiac Catheterization 90 0,03

6 I-1-06 Cardiothoracic Surgery 770 0,23

7 I-1-07 Coronary Bypass Operation withou Cardiac Catheterization 482 0,15

8 I-1-11 Cardiac Defibrillator & Heart Assist System Insertion 26 0,01

9 I-1-12 Thoracic Vascular Operation 140 0,04

10 I-1-13 Abdominal Vascular Operation 82 0,02

11 I-1-14 Permanent Cardiac Pacemaker Insertion 82 0,02

12 I-1-15 Cardiac Catheterization 10.296 3,12

13 I-1-16 Revision of Cardiac Pacemaker & Defibrillator Revision Excluding Device Replacement

46 0,01

14 I-1-17 Ligation & Stripping of Vein 482 0,15

15 I-1-20 Other Operations of Circulatory System 3.836 1,16

16 I-1-30 Replacement of Cardiac Pacemaker & Defibrillator Device 373 0,11

17 I-1-40 Percutaneous Procedure of Cardiovascular System 6.565 1,99

17

No Cases or Misclassified?

Distribution of Cases by Adjacent CBG CMG I 2014: Surgical Cases (17)

Distribution of Cases by Adjacent CBG CMG I 2014: Medical Cases (15)

NoAdjacent

CBGDESKRIPSI

JumlahKasus

Persentase

18 I-4-10 Acute Myocardial Infarction 18.713 5,67

19 I-4-11 Acute & Subacute Endocarditis 89 0,03

20 I-4-12 Heart Failure 94.028 28,50

21 I-4-13 Deep Vein Thrombophlebitis 694 0,21

22 I-4-14 Unexplained Cardiac Arrest 1.982 0,60

23 I-4-15 Peripheral and Other Vascular Diseases 25.005 7,58

24 I-4-16 Atherosclerosis 21.191 6,42

25 I-4-17 Hypertension 97.093 29,42

26 I-4-18 Cardiac Congenital & Valvural Diseases 3.498 1,06

27 I-4-19 Cardiac Arrhythmia & Conduction Diseases 8.729 2,65

28 I-4-20 Angina Pectoris & Chest Pain 15.083 4,57

29 I-4-21 Syncope & Collapse 1.184 0,36

30 I-4-22 Cardiomyopathy 1.471 0,45

31 I-4-23 Malfunction Reaction & Complication of Cardiovascular Device or Operation 52 0,02

32 I-4-24 Other Circulatory System Disorders 17.118 5,19

18

19

All data claim of INA-CBG CMG I Cardiovascular in 2014 was mapped

into Thai DRG Version 5.0

Result:• 95% cases gruped into Thai DRG MDC

5 Cardiovascular• 5% cases grouped into other MDC

Number of Cases that grouped into other MDC

NO MDC N

1 Diseases and Disorders of the Nervous System 107

2 Diseases and Disorders of the Eye 3

3 Diseases and Disorders of the Ear, Mouth and Throat 184

4 Diseases and Disorders of the Respiratory System 71

6 Diseases and Disorders of the Digestive System 204

7 Diseases and Disorders of the Hepatobiliary System and pancreas 35

8 Diseases and Disorders of the Musculoskeletal System and Connective Tissue 152

9 Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast 84

10 Endocrine, Nutritional and Metabolic Diseases and Disorders 45

11 Diseases and Disorders of the Kidney and Urinary Tract 121

12 Diseases and Disorders of the Male Reproductive System 24

13 Diseases and Disorders of the Female Reproductive System 21220

NO MDC N

14 Pregnancy, Childbirth and Puerperium 360

15 Newborns and Other Neonates with Conditions Originating in the Perinatal Period 309

16 Diseases and Disorders of the Blood and Blood Forming Organs and Immunological Disorders 16

17 Myeloproliferative Diseases and Disorders, Poorly Differentiated Neoplasms 53

18 Infectious and Parasitic Diseases (Systemic or Unspecified Sites) 125

19 Mental Diseases and Disorders 1

21 Injuries, Poisonings and Toxic Effects of Drugs 815

22 Burns 15

23 Factors Influencing Health Status and Other Contacts with Health Services 35

24 Multiple Significant Trauma 289

25 Human Immunodeficiency Virus (HIV) Infections 1

26 OR Procedure unrelated to Primary Diagnosis 2.470

28 One day care (LOS <=1) 9.851

21

Number of Cases that grouped into other MDC

Example Misclassification in MDC 5

Tarif INA CBG (Rp 41.165.700 ; Rp 64.970.600 ; Rp 103.790.100)

No Adjacent Thai DRG DESCRIPTION N

1 0501 Valve replacement and open valvuloplasty with cath 19

2 0502 Valve replacement and open valvuloplasty 209

3 0504 Coronary bypass with cath 5

4 0505 Coronary bypass 58

5 0532 Multiple cardiac valve procedure with cardiac cath 4

6 0533 Multiple cardiac valve procedures 185

7 0537 Complex cardiothoracic procedures 6

8 0552 Acute Myocardial Infarction with major comp, not transferred 1

22

Heart Valve Procedures without Cardiac Catheterization

23

MISCLASSIFICATION AND RISK FOR BPJSK

Example: Case-1

Patient 52 years old. Primary Diagnosis is I71.0 (Dissection of aorta). Secondary Diagnosis are: I13.1 (Hypertn hrt & ren dis w ren fail'r) I24.9 (Acute ischaemic heart disease, unspecified) I35.1 (Aortic (valve) insufficiency) K29.7 (Gastritis, unspecified) K80.2 (Calculus of gallbdr w/o cholecystitis)

Procedures :1. 3522 (Replace aortic valve NEC)2. 4513 (Sm bowel endoscopy NEC)3. 8855 (Coronar arteriogr-1 cath)

INA-CBG : Heart Valve Procedures withoutCardiac Catheterization (Tarif Reg 1, RS A,

kelas 1 severity II Rp. 90.958.800)

THAI DRG : Valve replacement and open valvuloplasty with cath

INA-CBG : Heart Valve Procedures withCardiac Catheterization

(Tarif Reg 1, RS A, kelas 1 severity II Rp. 72.073.700)

Procedures :1) 390 (Systemic-pulm art shunt)2) 598 (Ureteral catheterization)3) 3727 (Cardiac Mapping)4) 8952 (Electrocardiogram)5) 8954 (Electricardiographic Monitoring)6) 9056 (Microscopic examination of blood, Cell block and

papanicolaou smear)7) 9396(Other oxygen enrichment)8) 9399 (Other oxygen enrichmen)9) 9633 (Gastric lavage)10) 9918 (Injection or infusion of electrolytes)11) 9929 (Injection or infusion of other therapeutic or prophylactic

substance)12) 9960 (Cardiopulmonary resuscitation, not otherwise specified)

MISCLASSIFICATION AND RISK FOR HOSPITAL

24

Contoh Kasus Risiko bagi FKRTLPatient 52 years old. Primary Diagnosis is I25.6 (Silent myocardial ischaemia). Secondary Diagnosis are : I61.9 (Intracer hem, unspecified) N28.9 (Disorders of kidney & ureter, unspec)

INA-CBG : Atherosclerosis Severity Level 3(Tarif Reg 1, RS B, kelas 1 Rp. 6.018.100)

• THAI DRG : adjacent Major Cardiovasculare Procedure

• INA-CBG : Cardiothoracic Surgery• (Tarif Reg 1, RS B, kelas 1 Rp. 16.968.300 – Rp.

31.257.400)

• This case occurred in Class B Hospital in West Java.• After checking it turned out that the hospital did not

have the human resources and facilities to carry out the Systemic-Pulm art Shunt action (ICD 9CM 390)

• Credentialing is a tools to measure the hospital capacity

Misclassification creates Fraud

25

Example: Case-1

Patient 38 years old. Primary diagnosis is O14.1 (Severe Pre Eclampsia). Secondary diagnosis are O82.1 (Delivery by emergency caesarean section). Procedures :

1) 39.98 (Control of hemorrhage, not otherwise specified) Angiotripsy, Control of postoperative hemorrhage NOS, Venotripsy)

2) 57.94 (Insertion of indwelling urinary catheter)3) 74.1 (Low cervical cesarean section)4) 96.59 (Other immobilization, pressure, and

attention to wound)5) 99.18 (Injection or infusion of electrolytes)6) 99.21 (Injection of antibiotic)7) 99.22 (Injection of other anti-infective)8) 99.29 (Injection or infusion of other therapeutic or

prophylactic substance)

INA-CBG : adjacent Other Operations of Circulatory System(Tarif Reg 1, RS A, Kelas 3 Rp. 26.405.800 – Rp. 34.677.300)

Thai DRG : adjacent Caesarean delivery without complicating diagnosis

INA-CBG : Caesarean Section (Tarif Reg 1, RS A, kelas 3 Rp.

5.237.900 – Rp. 7.915.300)

26

Example Case -2

Patient 54 years old. Primary Diagnosis E11.2 (Non-insulin-dependent diabetes mellitus with renal complications).Secondary Diagnosis : J81 (Pulmonary oedema) N08.3 (Glomerular disorders in diabetes mellitus)

Procedures : 3995 (Hemodialysis) 8749 (Other chest x-ray) 8852 (Angiocardiography of right heart structures) 9059 (Microscopic examination of blood, Other

microscopic examination) 9129 (Microscopic examination of specimen from

kidney, ureter, perirenal and periureteral tissue, Other microscopic examination)

9396 (Other oxygen enrichment) 9905 (Transfusion of platelets)

INA-CBG : adjacent Cardiac Catheterization

(Tarif RS Reg.1, RS.B kelas 3 (severity III) Rp. 18.118.518)

• THAI DRG : Other kidney and urinary tract diagnoses

• INA-CBG : Other renal and Urinary Tract Disease

• (Tarif RS Reg.1, RS.B kelas 3 Rp. 3.314.200 – Rp. 7.909.600)

Misclassification creates Fraud

RISK FOR BPJSK AND HOSPITAL: Wrap-up

27

Number of cases (Exclude Cardiac Catheterization

and One day care) 307.896 cases

Risk for BPJSK 3% (7.752 cases); Rp 318.432.115.525

Risk for Hospital 0,4% (1.227 cases); Rp 8.504.595.652

Cardiac Catheterization and One day care

Adjacent I-1-20 (Other Operations of Circulatory System)

• I-1-20 cases are spread to more than 100 Adjacent outside MDC 5;

• The following table presents 20 Adj with the most cases.

28

Misclassification of Adjacent I-1-20 (Other Operations of Circulatory System)Tarif INA CBG (Rp 26.405.800 ; Rp 32.988.100 ; Rp 34.677.300)

No MDC Adjacent Thai DRG Deskripsi N

1 26 2650; 2651; 2652Ungroupable; Unacceptable principal diagnosis; Unacceptable obstetric diagnosis combination

319

2 02; 21 0210; 2101; 2104Enucleation and orbital procedure for eye malignancy; Wound debridement for injuries; other OR procedures for Injuries

273

3 24 2410; 2411; 2413

Abdominal with lower extremity procedure for Multiple significant trauma; Intracranial procedur for multiple significant trauma; Other OR procedure for multiple significant trauma

272

4 14 1401; 1402; 1403 Caesarean delivery without complicating diagnosis; Vaginal delivery with complication OR procedures with sever, multiple complicating diagnosis

244

5 03 0310 Other ear, nose, mouth & throat procedures 162

Adjacent I-1-20 (Other Operations of Circulatory System)No MDC Adjacent Thai DRG Deskripsi N

6 13 1311; 1316Other female reproductive system OR procedures; lap uterine and adnexal procedures

110

7 131302; 1304; 1305;1307

Uterine & adrenal procedure for other malignancy; Uterine & adrenal procedure for ovarian & adnexal malignancy; Uterine & adnexal procedure for non malignancy; Vaginal, cervix& vulva procedures

102

8 28 2837 Length of Stay 6 hours or less w other OR procedure 102

9 141452,1453,1454;145

5;1456,1457,1458

Antenatal condition without severe complicating diagnosis; Ectopic pregnancy; threatened abortion; Abortion; False labour; Complicated abortion, Molar pregnancy

92

10 111102; 1104;1107;

1109

Operative insertion peritoneal cath for dialysis; Kidney, ureter, and major bladder procedure; Transurethral procedure, exclude prostatectomy; Other kidney and urinary tract OR procedure

89

11 08 0822 Other musculoskeletal & connective tissue OR procedures 72

12 06 0614 Other digestive system OR procedure 7113 06 0609 Anal & stomal procedure 58

29

Adjacent I-1-20 (Other Operations of Circulatory System)

No MDC Adjacent Thai DRG Deskripsi N

14 171701; 1702; 1703;

1704

Lymphoma and Leukimia with major OR procedure; Other neoplastic disorders with major OR procedure; Lymphoma and Leukimia with other OR procedure; Other neoplastic disorders with other OR procedure

47

15 15 1510; 1511Newborn, admission wt>2499 gm with minor procedure; Newborn with major procedure

42

16 18 1803; 1804; 1805

Other procedure level 3 for infectious and paracitic diseases; OR procedure level 4 for infectious and paracitic diseases; OR procedure level 5 for infectious and parasitic diseases

40

17 01; 100105; 1050; 1051; 1053; 1054; 1056

Extracranial vascular procedures; Diabetes with complicated primary diagnostic; Severe metabolic disorder in adult; Nutrition and miscellaneous metabolic disorders; Inborn error of metabolism; Diabetes without complicated primary diagnosis

38

18 09 0909 Other skin, subcutan tissue and breast procedure 3519 10 1010 Other endocrine, nutritional & metabolic OR procedures 2720 08 0820 Soft tissue procedures 27

30

MUTLAK dilakukan pendalaman khusus terhadap Pengelompokan kasus I-1-20tersebut diatas

Improvement of INA CBG 5.1

Re-input is done to grouper 4.1 and 5.1. 163 cases data randomly selected 81% have the same results between 4.1 and 5.1, while 19% have differentresults between 4.1 and 5.1

31

Example :

There are misclassification in INA-CBG 4.0.

There are weaknesses in filtering the logic between diagnosis and procedure

This creates the opportunity/potential for fraud upcoding by adding certain diagnosis or procedure.

Misclassification cause overpaid and underpaid Risk for BPJSK and hospitals

Misclassification will give us the wrong information about Indonesian Health Status 32

Conclusion

1. Indonesia must develop the Native Grouper, The Real INA-CBGs Grouper

2. Regular update the classification system

3. Involve all stakeholders

4. Developed the standard competencies of the coder and verificator

33

Recomendation

TERIMAKASIH 34

Documents

Drill Down and the Need for Change: Maternal and ... · KASUS PERSALINAN BAYI JKN tahun 2014-2017 Juta Total Persalinan 6.8 ... 7 Diseases and Disorders of the Hepatobiliary System