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Case Mix in Romania: From Project(s) to National Scale Implementation Dana Burduja, JSI Romanian Case Mix in Romania: From Project(s) to National Scale Implementation Dana Burduja, JSI Romanian DRG Project Coordinator [email protected] ro Bucharest, November 2002 www. drg. ro

ROMANIA: 22, 500, 000 inhabitants 42 counties Capital – Bucharest, 2, 500, 000 inhabitants ROMANIA: 22, 500, 000 inhabitants 42 counties Capital – Bucharest, 2, 500, 000 inhabitants Social Health Insurance System (1997) 4. 2% of GDP for health (2002) – 70 USD per capita Main health system actors: Ministry of Health and Family – policy National Health Insurance House – financing College of Physicians – quality of care Providers – primary care, ambulatory, HOSPITALS, others www. drg. ro 2

Problems/Solutions • Underfinanced system • Non objective allocation to the • Increased % of Problems/Solutions • Underfinanced system • Non objective allocation to the • Increased % of GDP for health – POLITICAL big consumers – HOSPITALS decision !!! (70%) • Non efficient spending, waste at hospitals level • No evidence of hospitals outputs • CASE BASED FINANCING SYSTEM FOR HOSPITALS (technical and political decision) • Acceptable quality of care www. drg. ro 3

Practical Solution: Case Based Financing System OBJECTIVES: General Specific • Transparency in allocation of Practical Solution: Case Based Financing System OBJECTIVES: General Specific • Transparency in allocation of limited resources Transfer of technical tools to local and national institutions • Reduce inefficiency and waste at hospital consumption level • In country capacity for institutional buy-in and ownership • Data for health policies and hospital management • Quality of services maintained or increased at hospital level www. drg. ro 4

History of DRGs in Romania • 1995 – 1997: pilot 3 M/NCHS (project) • History of DRGs in Romania • 1995 – 1997: pilot 3 M/NCHS (project) • 1997 – 1999: pilot 3 M/NCHS (enlarged project) • 1999 – 2001: pilot DHHS/IHSM, complete piloting of the DRG system for University Hospital Cluj • 2000 – present: roll out DHHS/JSI/Romania National DRG Project All USAID funded www. drg. ro

DRG National Project INSTITUTIONS: TEAMS: • National Health Insurance House • Project Management • DRG National Project INSTITUTIONS: TEAMS: • National Health Insurance House • Project Management • Coding • Management Information Systems • Costing • Communication • Legislation/Policy/Regulation • Quality • Education • 23 Hospitals (I, U, C, M) • Ministry of Health and Family National Center for Health Statistics Institute for Health Services Management • College of Physicians • Ministry of Finance • 23 Hospitals (all types) • USAID Romania • DHHS, JSI, USA www. drg. ro 6

2001, 23 Project Hospitals • ICD 10 for dx, ICPM Ro version for procedures 2001, 23 Project Hospitals • ICD 10 for dx, ICPM Ro version for procedures • MBDS, clinical patient level data collection • Training • Grouping • Data analysis • Training • Department level cost data collection • Modeling the reimbursement scheme • Training • Preliminary national scale implementation plan www. drg. ro 7

2002, Project & Implementation • Actual case based reimbursement for project 23 hospitals (contracting, 2002, Project & Implementation • Actual case based reimbursement for project 23 hospitals (contracting, coding, data collection, grouping, financing etc) • ICD 10 coding training national level • Implementation Strategy Team operational • Data analysis operational (quality indicators) • Implementation strategy legislated and started to be implemented www. drg. ro

2002, Implementation • Contracting and financing of 23 hospitals • Implementation Strategy – team 2002, Implementation • Contracting and financing of 23 hospitals • Implementation Strategy – team and plan – operational • ICD 10 coding training national level • Clinical data collection prepared for the national level (software, medical record) • Cost data collection started national level • Data analysis ongoing (clinical and cost data) • Establishment of a Central Institution responsible for technical implementation www. drg. ro 9

www. drg. ro CMI ALo. S 10 2002 07 2002 06 2002 05 2002 www. drg. ro CMI ALo. S 10 2002 07 2002 06 2002 05 2002 04 2002 03 2002 02 2002 01 2001 12 2001 11 2001 10 2001 09 2001 08 2001 07 2001 06 2001 05 2001 04 2001 03 2001 02 2001 01 CMI and ALOS January 1, 2001 – July 31, 2002 days 0, 8 9 0, 7 8 0, 6 7 0, 5 6 5 0, 4 4 0, 3 3 0, 2 2 0, 1 1 0 0 year/month

11 Alte interv chirurg asupra sist. musc-scheletal si a tes conj fara CC 2, 11 Alte interv chirurg asupra sist. musc-scheletal si a tes conj fara CC 2, 5% Boli ale fic cu exc tumorilor, cirozei, hepatitei alcool fără CC Avortul cu dilatare şi chiuretaj, chiuretaj prin aspir. sau hist. Insuficienţa cardiacă şi şocul Probleme medicale spatelui Nou-născutul normal Otită medie şi inf resp. sup. vârsta 0 -17 ani www. drg. ro Naşterea vaginală fără dg complicat Hipertensiunea arterială Top 10 Romanian DRGs compared with Hungarian data 3, 0% % cases Hungary % cases Romania 2, 0% 1, 5% 1, 0% 0, 5% 0, 0%

www. drg. ro Boli ale ficatului cu exc tumorilor, cirozei, hepatitei alcool fara CC www. drg. ro Boli ale ficatului cu exc tumorilor, cirozei, hepatitei alcool fara CC Avortul cu dilatare si chiuretaj, chiuretaj prin aspiratie sau histerectomie Insuficienta cardiaca si socul Probleme medicale spatelui Nou-nascutul normal 12 Alte interv chirurg asupra sist. musc-scheletal si a tes conj fara CC 10 Otita medie si inf resp. sup. varsta 0 -17 ani 12 Nasterea vaginala fara dg complicat Hipertensiunea arteriala ALOS for Romanian top 10 DRGs compared with Hungarian data 14 ALo. S Hungary ALo. S Romania 8 6 4 2 0

2003 and Beyond • Financing 23+ hospitals • Ongoing implementation strategy refined • Data 2003 and Beyond • Financing 23+ hospitals • Ongoing implementation strategy refined • Data collection ALL hospitals • Data analysis ongoing • Refined reimbursement scheme • Central Institution running the implementation www. drg. ro

Challenges • Limited funds central and local level • Poor dialogue at political and Challenges • Limited funds central and local level • Poor dialogue at political and technical level, central and/with local • Competing and often conflicting incentives within the health care system • Poor history of team work, defined and assumed ownership and leadership www. drg. ro

Factors of Success • Technical tool to address several goals and objectives • Built Factors of Success • Technical tool to address several goals and objectives • Built in country technical expertise • 2 levels of support – technical to induce political, and political to support technical • Action – real piloting of the implementation • Build and transfer the leadership and the ownership www. drg. ro

Achievements & Lessons Learned • Political support, leadership and ownership assumed both at central Achievements & Lessons Learned • Political support, leadership and ownership assumed both at central level and local level • Development of a core of local experts/technical assistance and piloting of the case based financing tools • National scale implementation planned and agreed for all Romanian acute care hospitals by the end of 2004. www. drg. ro

THANK YOU FOR YOUR ATTENTION, GREETINGS FROM ROMANIA! www. drg. ro 17 THANK YOU FOR YOUR ATTENTION, GREETINGS FROM ROMANIA! www. drg. ro 17