Case Mix in Romania: From Projects to National Scale Implementation

1
Case Mix in Romania From Project(s) to
National Scale Implementation

• Dana Burduja, JSI
• Romanian DRG Project Coordinator
• dburduja_at_cmb.ro
• Bucharest, November 2002

2
ROMANIA 22,500,000
inhabitants42 countiesCapital Bucharest,
2,500,000 inhabitantsSocial Health Insurance
System (1997)4.2 of GDP for health (2002) 70
USD per capitaMain health system
actorsMinistry of Health and Family
policyNational Health Insurance House
financingCollege of Physicians quality of
careProviders primary care, ambulatory,
HOSPITALS, others
3
Problems/Solutions

• Underfinanced system
• Non objective allocation to the big consumers
  HOSPITALS (70)
• Non efficient spending, waste at hospitals level
• No evidence of hospitals outputs
• Acceptable quality of care

• Increased of GDP for health POLITICAL
  decision !!!
• CASE BASED FINANCING SYSTEM FOR HOSPITALS
  (technical and political decision)

4
Practical Solution Case Based Financing System

• OBJECTIVES
• General
• Transparency in allocation of limited resources
• Reduce inefficiency and waste at hospital
  consumption level
• Data for health policies and hospital management
• Quality of services maintained or increased at
  hospital level

• OBJECTIVES
• Specific
• Transfer of technical tools to local and national
  institutions
• In country capacity for institutional buy-in and
  ownership

5
History of DRGs in Romania

• 1995 1997 pilot 3M/NCHS (project)
• 1997 1999 pilot 3M/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

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DRG National Project

• INSTITUTIONS
• National Health Insurance House
• 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

• TEAMS
• Project Management
• Coding
• Management Information Systems
• Costing
• Communication
• Legislation/Policy/Regulation
• Quality
• Education
• 23 Hospitals (I, U, C, M)

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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

8
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

9
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

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CMI and ALOS January 1, 2001 July 31, 2002
CMI
days
year/month
11
Top 10 Romanian DRGs compared with Hungarian data
12
ALOS for Romanian top 10 DRGs compared with
Hungarian data
14
ALoS Hungary
12
ALoS Romania
10
8
6
4
2
0
Nou-nascutul normal
Hipertensiunea arteriala
complicat
Nasterea vaginala fara dg
Insuficienta cardiaca si socul
histerectomie
Avortul cu dilatare si chiuretaj,
chiuretaj prin aspiratie sau
Probleme medicale ale spatelui
CC
Alte interv chirurg asupra sist.
musc-scheletal si a tes conj fara
Boli ale ficatului cu exc tumorilor,
cirozei, hepatitei alcool fara CC
0-17 ani
Otita medie si inf resp. sup. varsta
13
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

14
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

15
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

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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.

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• THANK YOU FOR YOUR ATTENTION,
• GREETINGS FROM ROMANIA!