What to expect in AR-DRG Version 10.0
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The document discusses the updates and refinements outlined in the Australian Refined Diagnosis Related Groups (AR-DRG) version 10.0, focusing on approaches to classification development, stakeholder consultation outcomes, and specific areas of review including caesarean section classifications and personality disorder categorizations. It details the timeline of AR-DRG developments and key changes to clinical complexity models and intervention groupings, specifically highlighting issues like maternity care pricing and revisions in nephrolithiasis interventions. Final decisions on the proposals have been made, with the new version expected to be released in mid-2019.
What to expect in AR-DRG Version 10.0
- 1. What to expect in AR-DRG Version 10.0 Joanne Fitzgerald Executive Director, Policy and Classification
- 2. www.ihpa.gov.au Overview • Approach to classification development • Areas of review for consideration in the new version • In depth focus on two change proposals • Final outcomes and areas of refinement for Australian Refined Diagnosis Related Groups (AR-DRG) V10.0 2
- 3. www.ihpa.gov.au AR-DRG Classification System • AR-DRG classification groups together treatments and services provided to admitted patients • ICD-10-AM diagnosis codes and ACHI procedure codes are used to assign an episode of care to an AR-DRG • Some other factors may also be considered for certain AR-DRGs ‒Length of stay ‒Admission weight for neonates ‒Transfer or discharge status3
- 4. www.ihpa.gov.au Timeline of AR-DRG Development Release of V8.0 July 2015 Pricing using V8.0 July 2016 Release of V9.0 July 2017 Pricing using V9.0 July 2018 Release of V10.0 July 2019 Pricing using V10.0 July 2020 4
- 5. www.ihpa.gov.au AR-DRG assignment 5 Demographic and Clinical edits Pre MDC Processing MDC Processing Adjacent DRG Processing DRG Allocation AR-DRG V9.0 AR-DRG V8.0
- 6. www.ihpa.gov.au Approach to AR-DRG development Work program Clinical review Analytical assessment Stakeholder consultation Finalise AR- DRG V10.0 6
- 7. www.ihpa.gov.au Areas of review for AR-DRG V10.0 • Episode clinical complexity model ‒Diagnoses excluded from episode complexity calculations ‒Stability of episode complexity calculations between versions • Caesarean sections • Nephrolithiasis interventions • Public submissions 7
- 8. www.ihpa.gov.au Areas of review for AR-DRG V10.0 • Review of each MDC hierarchy • Review of complexity splits and thresholds for every adjacent DRG • For full details of all proposals reviewed, refer to Consultation Paper on Australian Refined Diagnosis Related Groups Version 10.0 8
- 9. www.ihpa.gov.au In focus – caesarean sections • A number of DRG systems used internationally, including in the United Kingdom and Germany, distinguish between emergency and elective caesareans, and price them differently • Stakeholders have argued that the AR-DRG classification inappropriately incentivises caesarean deliveries by pricing them higher than vaginal deliveries 9
- 10. www.ihpa.gov.au Clinical review • Noted that differentiating between ‘emergency’ and ‘elective’ interventions may create a precedent • Noted that there were not consistent clinically derived national definitions for ‘emergency’ and ‘elective’ caesareans • Strong support from midwives and peak body representing women’s hospitals to differentiate caesarean sections on basis of ‘in labour’ and ‘not in labour’ caesareans 10
- 11. www.ihpa.gov.au Analytical assessment Caesarean delivery Emergency Elective % Difference (a) (b) (c) =(a)/(b)-1 Public Hospitals Number of episodes 31,635 32,237 Percentage of episodes 49.53% 50.47% Average length of stay 4.53 3.59 26.1% Average cost $11,997 $9,966 20.4% 11
- 12. www.ihpa.gov.au Analytical assessment 12 Caesarean delivery Episodes with labour codes Episodes without labour Codes % Difference (a) (b) (c) =(a)/(b)-1 Public Hospitals Number of episodes 38,993 24,881 Percentage of episodes 61.05% 38.95% Average length of stay 4.57 3.26 39.9% Average cost $11,954 $9,433 26.7%
- 13. www.ihpa.gov.au Stakeholder consultation 13 • Position was to create two new adjacent DRGs for caesarean sections, one for ‘in labour’ caesareans and one for ‘all other’ caesareans • Broad consultation as part of the AR-DRG V10.0 public consultation in June 2018 • Mixed feedback
- 14. www.ihpa.gov.au Final decision for AR-DRG V10.0 14 $0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 O01A O01B O01C ORIGINAL CAESAREAN COST DISTRIBUTION $0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 O06A O06B O07A O07B PROPOSED CAESAREAN COST DISTRIBUTION
- 15. www.ihpa.gov.au In focus – personality disorders • A submission from WA noted that personality disorder diagnoses accounted for a high volume of admitted mental health services and requested consideration of further breakdown of this adjacent DRG to differentiate between the different clinical needs of patients U67A Personality Disorders and Acute Reactions, Major Complexity U67B Personality Disorders and Acute Reactions, Minor Complexity 15
- 16. www.ihpa.gov.au Clinical review • Noted that there is a specific classification for mental heath that will replace AR-DRGs as the classification for patients receiving mental health care • Noted the volume and types of personality disorders being reported as principal diagnoses 16
- 17. www.ihpa.gov.au Clinical review Principal diagnosis category Number of episodes Percentage of episodes Stress reactions and adjustment disorders 10,158 55.1% Specific and mixed personality disorders 7,417 40.2% Conduct disorders and mixed disorders of conduct and emotions 632 3.4% Other 142 0.8% Gender identity disorders, disorders of sexual preference and disorders associated with sexual development and orientation 34 0.2% Habit and impulse disorders 30 0.2% Enduring personality changes 11 0.1% Sexual dysfunction 10 0.1% Total 18,434 100.0% 17
- 18. www.ihpa.gov.au Analytical assessment 18 Complexity Split Cohort Statistic A B Total Episodes 3,715 14,719 18,434 Total ADRG Average Cost $13,384 $6,097 $7,566 Average Length of Stay 9.83 4.24 5.37 Episodes 1,945 8,213 10,158 Stress reactions and adjustment disorders Average Cost $12,308 $6,099 $7,288 Average Length of Stay 9.06 4.13 5.07 Episodes 1,523 5,894 7,417 Specific and mixed personality disorders Average Cost $14,727 $6,154 $7,915 Average Length of Stay 10.94 4.48 5.81 Episodes 247 612 859 Other Average Cost $13,573 $5,521 $7,836 Average Length of Stay 9.10 3.40 5.04
- 19. www.ihpa.gov.au Stakeholder consultation 19 • Position was not to proceed with any refinements to U67 Personality Disorders and Acute Reactions • Broad consultation as part of the AR-DRG V10.0 public consultation in June 2018 • Support from stakeholders not to pursue a refinement to this adjacent DRG • Therefore, final decision was no change for AR-DRG V10.0
- 20. www.ihpa.gov.au What can you expect to see in AR-DRG V10.0 20 • Refinements to the episode clinical complexity model ‒Changes to diagnosis codes in-scope for receiving a Diagnosis Complexity Level (DCL) ‒Stabilisation measures introduced to the calculation of DCLs ‒Recalculation of DCLs based on updated cost data ‒Review of the number of ‘complexity splits’ and thresholds for ‘complexity splits’ for every adjacent DRG
- 21. www.ihpa.gov.au What can you expect to see in AR-DRG V10.0 21 • Nephrolithiasis interventions (to be confirmed) ‒More clinically coherent groupings for nephrolithiasis interventions ‒Removing the same day variable that resulted in some episodes with nephrolithiasis interventions being classified to a medical DRG if they were overnight admitted episodes
- 22. www.ihpa.gov.au What can you expect to see in AR-DRG V10.0 22 ADRG Current Criteria (AR-DRG V9.0) New Criteria (AR-DRG V10.0) L40 Ureteroscopy intervention Combine L40 and L41: Ureteroscopy intervention and exclude episodes with nephrolithiasis principal diagnosis L41 Cystourethroscopy intervention and a sameday episode Combine L40 and L41: Cystourethroscopy intervention and exclude episodes with nephrolithiasis principal diagnosis Remove the sameday criterion L42 Nephrolithiasis principal diagnosis and Extracorporeal Shock Wave Lithotripsy of urinary tract intervention Remove ADRG as it becomes obsolete as these episodes would be captured in L43 L43 New Based on specified nephrolithiasis principal diagnoses and interventions
- 23. www.ihpa.gov.au What can you expect to see in AR-DRG V10.0 23 • Removal of Z60 Rehabilitation as this adjacent DRG is redundant following Ninth Edition coding standard changes • Reassignment of episodes of liver procurement from a living donor to a body system MDC • Reassignment of osseointegration interventions of digit and limbs to a more clinically appropriate adjacent DRG
- 24. www.ihpa.gov.au Next steps 24 • Final approval process through IHPA’s advisory groups • Preparation of AR-DRG V10.0 report outlining all refinements • Approval from the Pricing Authority in February 2019 • Release of system materials including groupers, definitions manual and education resources mid-2019