FK Understanding the Surgical Workload - HPO...Understanding the Surgical Workload and its Funding...

Understanding

the Surgical

Workload and

its Funding

Activity Based Funding Conference

28th May 2015

1. Providers are funded based on the activity they undertake.

2. ‘Casemix funding’ is also used = ‘mix of cases’ that a health service

treats.

3. A health system produces more than treated cases, and includes

maintaining the health of people at home, prevention, teaching,

research etc

4. For this reason, no health system in the world is funded solely on

the basis of its ‘casemix’.

5. Hospital activity is counted by ‘episode of care’- from admission to

discharge

6. The financial incentive is to minimise the cost of each episode of

care

7. Inevitably rewards the shortest length of stay in a hospital bed

8. This raises concerns that patients will be discharged too soon.

9. These concerns can be overcome if patient outcomes are

measured

10. These concerns can be overcome if there is continuity of care

between the hospital and home.

ACTIVITY BASED FUNDING

28/05/2015 ACTIVITY BASED FUNDING 2

Encrypted

The ABF Patient

Record Journey

Who sets the price?

16,708HIPE

30/admission

6,662HIPE

20/admission

FUNDING


28/05/2015 ACTIVITY BASED FUNDING

DRG codes

XnnS

Step 1: Major Diagnostic

Category (MDC) code

• 23 body systems

• A = complex – Transplant,

prolonged ICU

Step 2: ADRG number

• Surgery 00…39;

• Other 40…59 (eg Echmo, Plasmaphoresis)

• Medicine 60…99

Step 3: Complexity

A = most complex …

D = least complex

(or Z – same price

regardless)split

698 DRGs in

Ireland4


HIPE finalised data file, 2013

DRG / Procedure # Patients AvLOS

Avg Rel

Cmplxty

MJR SMALL & LARGE BOWEL PR-CCC (G02B) 1,480 11.28 7.27

Right hemicolectomy with anastomosis (3200301) 403 9.86 8.14

Limited excision lrg intestine w anstms (3200300) 171 9.70 6.80

Resec small intestine w anastomosis (3056600) 169 12.51 4.97

Left hemicolectomy with anastomosis (3200600) 93 9.83 8.14

Temporary colostomy (3037528) 71 12.18 6.47

Extended right hemicolectomy w anstms (3200501) 55 11.67 8.14

Total colectomy with ileostomy (3200900) 49 15.18 11.43

Abdominal rectopexy (3211700) 47 7.23 6.47

Temporary ileostomy (3037529) 46 12.17 6.02

Subtotal colectomy w stoma formation (3200400) 42 21.33 8.59

Limited exc lrg intestine w stoma frm (3200000) 41 11.73 8.59

Reduction rectal mucosa, rectal prolapse (3211100) 39 4.31 5.58

Subtotal colectomy w anstms (3200500) 26 12.42 11.43

Left hemicolectomy w stoma formation (3200601) 19 16.53 8.14

Total colectomy w ileorectal anastomosis (3201200) 18 11.11 11.43

Other repair of small intestine (3037519) 18 8.06 5.58

Right hemicolectomy w stoma formation (3200001) 17 14.82 8.14

Laparoscopy (3039000) 16 17.38 4.24

Resec small intestine w formation stoma (3056500) 16 21.44 6.02

Other colostomy (3037504) 14 11.57 6.47

⁞ ⁞ ⁞ ⁞ ⁞ ⁞ ⁞ ⁞

DRGS ARE FOR FUNDING AND NOT FOR DRGS ARE FOR FUNDING AND NOT FOR DRGS ARE FOR FUNDING AND NOT FOR DRGS ARE FOR FUNDING AND NOT FOR

CLINICIANS MEASURING THEIR ACTIVITYCLINICIANS MEASURING THEIR ACTIVITYCLINICIANS MEASURING THEIR ACTIVITYCLINICIANS MEASURING THEIR ACTIVITY

THIS IS DONE BY HIPETHIS IS DONE BY HIPETHIS IS DONE BY HIPETHIS IS DONE BY HIPE


28/05/2015ACTIVITY BASED FUNDING

7

Our analysis:

• By patient episode, by primary

procedure

• Procedures* (mainly PRIMARY)

drive surgical DRGs and ABF

• Procedures > 20 in any one year in

all surgery (2010, 2011, 2012, 2013)

Excluding procedures < 10 in 2013

NCPS Mapping of Surgical Procedures

>98%

Patients who had an Above Knee Amputation (4436700) during a single admissions in 2012

PRIMARY


Multiple

Procedure

Example

HIPE CAN COLLECTUPTO 30 DIAGNOSES

& 20 PROCEDURES



NQAIS

Surgery

Web enabled

interactive

reporting tool

Using your own

hospital’s HIPE data

HOW ABF WILL DRIVE CLINICAL PRACTICE

1. BY IMPROVING EFFICIENCY AND QUALITY OF CARE BY SETTING

APPROPRIATE TARIFFS

2. BY CORRECTING PERVERSE INCENTIVES - DAY v INPATIENT ACTIVITY

3. BY FUNDING CARE IN CORRECT SETTING - AMBULATORY CARE

4. BY INCENTIVISING SHORTENED AVLOS

5. BY INCENTIVISING BETTER CARE

6. BY MANAGING INAPPPROPRIATE GEOGRAPHIC VARIATION

7. BY LIMITING OVER INVESTIGATION AND OVER TREATMENT



€3,226 PerCase€3,226 PerCase




Elective

HIPE data

2013

LAP CHOLECYSTECTOMY-CDE-CSCC (H08B)

We need

Day Case

We need to

incentivise

move to

Day Case

National target 60%

Expense

€5539/week €12,798 /week

BY FUNDING CARE IN CORRECT SETTING - AMBULATORY CARE


Day Surgical

Procedures

85,140

39%

GI

Endoscopes

51,456

23%

Minor Opp

29,537

13%

Out Patient

Proc

42,863

19%

Examining 2012 Surgical Day Case Activity

Day Procedures

(not true Day Surgery)

68,400

38%

N= 208,996

OUT PATIENTS

Examination of the Eye

Nasoendoscopy

Aspiration of breast

Fine needle biopsy of breast

Rigid sigmoidoscopy

Sclerotherapy for haemorrhoids

Ear toilet, unilateral

Papanicolaou smear study

Micro injections of venular flares

Should be done as Day Cases. Funding should reflect the correct site

Valid

Day

Case

MINOR OPS – SIDE ROOM

Removal of toenail or in-growing toenail

Biopsy of skin & subcutaneous tissue

Excision of lesion(s) SSCT, foot

Biopsy of tongue

Biopsy of oral cavity

Removal of wart


Transfers – Acute Hip fracture operations in receiving hospital


Transferred from Acute Hospital / HIPE hospital list or from non-Acute Hospital (Admit source 3 or 4)

HIPE 2013 data

Operating Hospital # Patients BDU AvLOS # Patients BDU AvLOS # Patients BDU AvLOS

AMNCH Tallaght 133 2,955 22.2 26 502 19.3 159 3,457 21.7 16.4%

BEAUMONT HOSPITAL, DUBLIN 189 5,693 30.1 4 154 38.5 193 5,847 30.3 2.1%

CONNOLLY HOSPITAL, BLANCHARDSTOWN 58 1,915 33.0 0 0 0.0 58 1,915 33.0 0.0%

CORK UNIVERSITY HOSPITAL 280 4,034 14.4 5 71 14.2 285 4,105 14.4 1.8%

KERRY GENERAL HOSPITAL 138 1,786 12.9 0 0 0.0 138 1,786 12.9 0.0%

LETTERKENNY GENERAL 105 1,722 16.4 1 129 129.0 106 1,851 17.5 0.9%

MATER MISERICORDIAE, DUBLIN 132 3,731 28.3 2 26 13.0 134 3,757 28.0 1.5%

MAYO GENERAL HOSPITAL 84 2,017 24.0 0 0 0.0 84 2,017 24.0 0.0%

MIDLAND REGIONAL HOSPITAL, TULLAMORE 115 1,647 14.3 6 57 9.5 121 1,704 14.1 5.0%

OUR LADY OF LOURDES, DROGHEDA 152 2,816 18.5 65 1,240 19.1 217 4,056 18.7 30.0%

REGIONAL (UCHG), GALWAY 101 1,900 18.8 4 56 14.0 105 1,956 18.6 3.8%

REGIONAL, (DOORADOYLE) LIMERIC 188 2,069 11.0 10 63 6.3 198 2,132 10.8 5.1%

SLIGO GENERAL HOSPITAL 80 1,078 13.5 0 0 0.0 80 1,078 13.5 0.0%

ST. JAMES'S HOSPITAL, DUBLIN 64 3,071 48.0 1 9 9.0 65 3,080 47.4 1.5%

ST. VINCENTS UNIVERSITY HOSPITAL 328 8,626 26.3 1 6 6.0 329 8,632 26.2 0.3%

TEMPLE ST. CHILDREN, DUBLIN 2 8 4.0 0 0 0.0 2 8 4.0 0.0%

WATERFORD REGIONAL (ARDKEEN) 258 4,635 18.0 142 2,512 17.7 400 7,147 17.9 35.5%

Grand Total 2,407 49,703 20.6 267 4,825 18.1 2,674 54,528 20.4 10.0%

Admitted direct Transfer from other Hospital Total % Transfer

from Hsptl

BY INCENTIVISING BETTER CARE - Hip Fracture

KPI – Surgery within 48 Hours

Elective 2013 Cases Per

Discharged to 000's Pop

City / County 01 9.21







⁞












Ireland Total 1.98

HIPE 2013 data

Extraction of Cataract w or

wo implant -

Lens procedures (C16Z)

4.7 times

national avg

Elective 2013 Cases Per

Discharged to 000's Pop








⁞













Ireland Total 0.31

HIPE 2013 data

for Adults only (16 & Over)

Tonsillectomy without

adenoidectomy -

TONSILLECTOMY,

ADENOIDECTOMY (D11Z)

2.6 times

national avg

BY MANAGING INAPPPROPRIATE GEOGRAPHIC VARIATION

BY LIMITING OVER INVESTIGATION AND OVER TREATMENT


http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande

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