Transcript Slide 1

Casemix in 2012/13 and beyond
Paula Monteith, the Casemix Service, NHS IC
Overview
• Deliverables in 2012
– Payment
• March 2012: Local Payment 2012/13
• Summer 2012: SenseCheck 2013/14
• Autumn 2012: RoadTest 2013/14
– Costing
• March 2012: Reference Costs 2011/12
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Deliverables in 2013
– Payment
• March 2013: Local Payment 2013/14
• Summer 2013: SenseCheck 2014/15
• Autumn 2013: RoadTest 2014/15
– Costing
• March 2013: Reference Costs 2012/13
• And Beyond…
– Patient Pathway Groups (PPGs)
Local Payment 2012/13: HRG4
Base
Reference Costs 2009/10 (but see LP 11/12 “out of synch” changes)
Number
1,527 HRGs (increase from 1,504 in LP 11/12)
OPCS
ICD-10
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OPCS 4.6 (TOCE back to OPCS-4.5 RC 2009/10 design structure)
ICD-10 4th Edition (TOCE back to ICD-10 RC 2009/10 design structure)
Key
Design
Changes
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Cross-chapter - enhanced length of stay logic for minor procedure HRGs to derive HRG
from primary diagnosis if length of stay is longer than pre-set minimum (2 days*)
Cancer Treatment Services (SB, SC) - Same Day admissions HRGs introduced for
Chemotherapy / Radiotherapy to capture core HRG where only treatment is unbundled
Dental Services (CZ) – 26 discrete HRGs for treatment of teeth
Cardiac Procedures (EA) – redesign to accommodate cardiac devices and procedures
Digestive (FZ) – net increase of 16 HRGs to better accommodate age, surgical
approach
• New endoscopy HRGs to differentiate scope type, diagnostic only, diagnostic with
biopsy, therapeutic and combined upper and lower GI tract
Maternity Services (NZ) – effective redesign of delivery HRGs to introduce planned,
emergency and with complications splits in C-sections, remove age splits, reflect
differential resource use of Epidural / Induction / Intervention
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Key
Technical
Changes
Flag Outputs
• Separate columns for each flag type (SSC, BPT and Flag)
• Will output flags for Non-Admitted Care (OP CDS)
• Will contain a prefix to denote the flag type to differentiate the sets (e.g. SS23 or BP88)
Reference Costs 2011/12: HRG4
Number
1,657 HRGs (increase from 1,559 in RC 10/11)
OPCS
ICD-10
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OPCS 4.6
ICD-10 (Not ICD-10 4th Edition)
Key
Design
Changes
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Cross-chapter – coding enhancements for “principal extended categories” (supports
adherence to coding standards and (hopefully) improved data quality
Cardiac Procedures (EA) – expansion of design to reflect (more) devices – e.g. EA57Z
Transcatheter Aortic Valve Implantation (TAVI)
Digestive (FZ) – increased granularity in HRGs for children (< 2 years, 2-18), improved
recognition of High Cost Devices, separate identification of surgery for obesity – e.g.
FZ85Z Restrictive Stomach Procedures for Obesity
Hepatobiliary Surgery (GA) – clarification of HRG content by removal of “category”
reference in labels
Orthopaedic Surgery (HA / HB / HR) – introduction of site-specific “minimal” HRGs
(more minor than “minor”) to narrow activity distribution of lower resource HRGs
Breast Surgery (JA) – refinements to support BPT identification – Mastectomies split
between “simple” and complex” reconstruction
Urological Surgery plus (LB) – introduction of age splits, acknowledgement of highly
specialised procedures – e.g. LB71Z Total Pelvic Exenteration
Maternity Services (NZ) – effective redesign of non-delivery HRGs to support Maternity
pathway aspirations (standard / specialised / complex)
Diagnostic Imaging (RA) – age splits for specific HRGs (MRIs, CTs) to identify children’s
activity, introduction of 3 new HRGs for Cardiac MRIs
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HRG4 Recap
Scope
Underpinned by 4 national standard datasets for :
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Services
Identified by OPCS (intervention / procedure) and ICD-10 (diagnosis) for:
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Method
All Surgical and Medical treatments, including
Major Trauma Care
Cancer Treatment Services
Maternity Services
Rehabilitation Services and
Specialist Palliative Care
Clinically owned (professional bodies), Policy Endorsed (Framework)
Procedure-precedence in grouping, with discrete care events “unbundled”
Recognition of additional resource use of:
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Benefits
Inpatient Care and Day Case Care (zero length of stay)
Critical Care (Intensive Care for Adults, Children, Neonates)
Outpatient Care (not admitted, hospital-based, includes interventions)
Emergency Medicine (not admitted, hospital-based, investigations)
Patient Characteristics – e.g. age, complications, comorbidities
Clinical Characteristics – e.g. multiple procedures
Costing, funding, benchmarking, service planning, performance measurement
The Catalyst for Change
Change in Government (May 2010) has seen transformation of healthcare
policy and national and local structures to commission / deliver it:
• Proposed Health and Social Care Bill 2011, will create new
organisational landscape with:
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Clearer demarcation of specialist service provision (limited number of
centres of excellence) and clearer responsibility for commissioning
(regional / national levels)
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Increasing number of groups responsible for commissioning of nonspecialist NHS services
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Increased need to identify “specialist” patient journeys at local / national levels
Clinical Commissioning Groups (GPs plus)
National organisations other than the Department of Heath taking
responsibility for establishing the scope, structure, and levels of national
tariff payment
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NHS Commissioning Board
Monitor
HRG4+ (expected RC 12/13)
Number
c. 1,800+ groups (2012/13)
Scope
Governed by national standard datasets as per HRG4, (APC, OP, CCMDSs, EM)
but extending to
• Community Care – see Community Information Data Set (April 2012)
Services
Identified by OPCS (intervention / procedure) and ICD-10 (diagnosis) for:
• All hospital-based Surgical and Medical treatments – see previous, plus
• Community Care (including nursing services, health visiting, outreach)
Method
Clinically owned (professional bodies), Policy Endorsed* (Framework)
Procedure-precedence in grouping, with discrete care events “unbundled” , but
• Improved recognition of diagnosis in APC, including recognising the multiply
comorbid (often with increasingly multiple interventions); extending the use of
proxies for severity of diagnosis (previously trialled), acknowledging the
interactive nature of (some) CCs - extended acknowledgement of truly
“specialised” services, especially for infants
• (New): Use of diagnosis in Outpatients, Emergency Medicine, Community
• Improved Quality Criteria – extended procedure hierarchies, re-instigation of
within chapter HRG relationship (renumbering, re-chaptering), and more
Benefits
Costing, funding, benchmarking, service redesign - especially for “specialist
services”: a response to the changing provider landscape
And Beyond: PPGs
Number
24 groupings initially (a working concept – 2013/2014?)
Scope
Uses national standard datasets across care continuum from :
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EM or Outpatient Care, through Admitted Patient Care to Community Care
Assumes diagnosis can be used as a “common language” across care settings
to identify patients with similar expected resource needs
Services
Identified by updated ICD-10 (diagnosis) (4th Revision) for 4 key service areas:
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Stroke (8)
Diabetes (5)
Chronic Obstructive Pulmonary Disease (COPD) (8)
End of Life Care (3)
Grouping logic requires ‘event’ qualification following diagnostic entry to pathway
Method
Initial premise: for a subset of patients, healthcare interventions during a
standard “year of care” can be indicated by diagnosis
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Based on National Institute for Health and Clinical Excellence (NICE) clinical standards
for care pathways for specific long-term conditions
Not a replacement for the HRG classification - uses HRGs to construct (therefore cost,
and price) the care pathway to establish “expected” care, and begin to measure deviation
from NICE “best practice” and / or the national norm, at a local level
Aims to cover multi-provider, multi-setting care that continues beyond a single care event
(e.g. disease management)
Designed to respond to the changing commissioner landscape
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And Beyond: PPGs (ii)
Benefits
For NHS commissioners, possibilities include :
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Value
Whether local healthcare delivery deviates from an approved clinical benchmark (NICE),
and from national / regional norms, and to use this evidence to improve commissioning in
future years;
A reduced administrative burden by commissioning care pathways that reflect the needs
of the local population without paying for individual events or paying for the same event
twice
Better visibility of the care provided across pathways and between settings, with
standardised identification of patients on a pathway, and those that could or should be,
but are not
Improved understanding of the link between commissioning of care and clinical
appropriateness and effectiveness at the patient level
NHS Costing (2009/10 approximations for admitted patient care medical
admissions, excluding unbundled events) :
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Stroke £493m (≈1.3%)
Diabetes £77m (≈0.2%)
Chronic Obstructive Pulmonary Disease (COPD) £232m (≈0.6%)
End of Life Care £69m (≈0.2%)
Summary
• HRG4 for 2012/13 LP (1,527) has substantially changed from
2011/12 LP (1,504)
– More age splits (infants) and length of stay splits as proxy for severity
– Greater precedence of diagnosis where appropriate
• HRG4 for 2011/12 RC (1,657) has substantially changed from
2010/11 RC (1,559)
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More CC splits and (infant) age splits
More multiple procedures where feasible (and codeable)
More HRGs to capture specific devices (nb – costs!)
Accommodation of funding policy requirements from 2012/13 LP
• Improved documentation is available:http://www.ic.nhs.uk/services/the-casemix-service/using-thisservice/reference/downloads
• But, improved specificity and sophistication requires better coding
and better costing
• HRG4 for 2012/13 RC will be HRG4+ (payment use subject to policy
decision)
The Casemix Vision
• To enrich the current HRG4 classification and respond to the changing
needs of the healthcare infrastructure
• Especially for providers of increasingly specialist care
• To prove the concept that PPGs are capable of recognising appropriate
and effective commissioning, in a standard and formalised manner
• For local and national health populations
• To continue to maintain yet develop a Casemix Product Suite that
supports innovative clinical practice and policy development
• And enhances understanding of care at the patient level
• Mystified, aghast, intrigued?
• [email protected]
• [email protected]