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UNU-CBG: New Casemix System Tool To
Enhance Quality and Efficiency in Developing
Countries
International Institute For Global
Health (UNU-IIGH)
Professor Dr Syed Mohamed Aljunid
MD (UKM) MSc (Public Health)( Singapore) PhD (London); DLSHTM
(London); FAMM
Professor of Health Economics & Consultant Public Health
Medicine
Senior Research Fellow
United Nations University-International Institute For
Global Health
Kuala Lumpur
Challenges in Social Health
Insurance Schemes in Developing
Countries
! Low coverage (breath and depth)
! Inadequate resources especially for social insurance
! Unaffordable Premium especially for poor and near poor
! Limited Benefit package
! High level of inefficiency
! High administrative cost
! Moral Hazards of Consumers and Providers
! Delay in claim processing
! Poor Provider Payment Mechanisms
! Use of retrospective payment methods (e.g. FFS/Itemised bill)
! Services Of Poor Quality
! Lack of proper review and monitoring
! Low patient satisfaction
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! Reduce Administrative Cost
! Should not be more than 10% of operating cost
! Control of moral hazards
Effective and efficient ways of controlling moral hazards
! Consumers: Co-payment
! Providers: Utilisation Review, Medical Audit
! Use efficient provider payment mechanism
! Regular Review of Benefit Package
! Include new services
! Exclude non-essential services
! Work with the Stakeholders
! Increase acceptance of consumers & providers
What is Casemix System ?
Casemix System is a classification
of patient treatment episodes
designed to create classes which
are relatively homogenous in
respect of the resources used and
which contain patients with
similar clinical characteristics.
(George Palmer, Beth Reid,2000)
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What is Casemix?
" Refers to the Type and Range of Cases
treated in hospitals and clinics
" Defines Hospital Final Output, Classified into
Predetermined Categories
" Provides Information on Resource Use and
Quality
" Describes patients characteristics including
outcome of care
" Can be used as standards for comparison
Benefits of Using Casemix
System
! Improve Efficiency of Health Care Services health
" Identify unnecessary services
" Reduce wastages and Cost Savings
! Improve Quality of Care
" Enhance Quality Assurance Programme
" Facilitate Benchmarking Exercise
" Improve Patient Satisfaction
! Improve Health Management Information System
" Provide high quality data on patient care
" Provide information for review and monitoring
" Promote Better Decision Making
" Encourage Evidence-Based Practice
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Case-mix System Reimbursement:
Advantages
! Risk shared between funders and providers
! Remove incentive to over treat patients
# Payment based on package
! Fair remuneration to providers
# Payment based on severity level
! Payment based on productivity
# Payment based on intensity of care not just volumes
! Enhance Quality Assurance Programme
! Transparency and objective in computation of tariff
Case-mix System
Reimbursement: Advantages
! Faster and easier to Process Payment
! Easier to verify claims
! Tariff can be easily updated
! Annual updating of Hospital Base-Rates
! Annual/Bi-Annual updating of Cost-weights
! Fraudulence Claims can be detected
and avoided
! Assignment of severity level by grouper
! Random checking can be easily done
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Global Use of Case-mix (2010)
Case-mix System in Developing Countries:
The Obstacles
! Lack of capacity
! Technical skills on Case-Mix System
! Managerial Capacity on the application of
case-mix System
! Limitations in health information system
! Quality of disease coding
! Diagnosis and procedure coding
! Limited costing data
! Unit cost data
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Casemix System in Developing Countries:
The Obstacles
! Limited Access to Casemix Tool
Casemix Groupers are mainly proprietary owned
Difficult to be customised for local need
Need access to source code for customisation
! Lack of Financial Resources
! Case-Mix Consultants are expensive
! Commercial Case-Mix Softwares are costly
! Slow acceptance by Practitioners
! No capacity to refine or expand case-Mix groupings
! No groupings for chronic diseases/subacute cases
! Tariff not updated
! No continuous refinement of DRGs groupings not refined
What Do We Do in
UNU-IIGH?......
! Build human resource capacity in
Casemix
! Series of Training Workshops
! E-learning Programme
! Support local development of casemix system
! Provide access to Casemix Tool
! Casemix Grouper
! Digital Coding Tool
! Clinical Costing Software
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Implementation of Case-Mix System in
Developing Countries
Disease &
Procedure Codes
Financial
Data
CCM
DRG-
Grouper
Cost-Weights
CUSTOMISED
DRG
GROUPER
Hospital Base
Rate
NATIONAL
HOSPITAL
TARIFF
Case-Mix Index
Softwares in Case-Mix System
! Digital Coding Tool
! Data Tool- Assist to enhance productivity of Coders
! UNU-Code Assist- Assist in Verifications of Casemix coding
and grouping
! Case-Mix Grouper
! UNU-CMG Grouper
! Costing Tool
! CCM Version 2.0-UKM/UNU
! Costing Template for Hospital Base-Rates
! Costing Template for National Tariff
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What is Case-Mix Grouper?
! Computer software used to carry out
grouping of patients into casemix
groups or DRGs based on the grouping
algorithms
! Grouper used all the information in the
minimum data set to group the cases
! Output of the grouper is the coded
casemix groups
Why do we need Case-Mix
Grouper?
! Case-mix algorithm is complex and
cannot be done manually
! Algorithm has many variables
! Grouper can do the grouping accurately
and efficiently
! Grouper can detect errors which can be
later rectified
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Weaknesses of Current Case-
mix Groupers ..
! Not designed to group sub-acute and chronic
cases
! Sub-acute cases
! Very complicated Cases
! Moderately long stay cases
! Chronic cases
! Mental illness
! Long term rehabilitation
! Social welfare cases
! Very long stay cases
Weaknesses of Current Case-
mix Groupers
! Produced unhomogenous DRG groups
! Tariff developed unsuitable for payment of
! Chronic Cases
! Cases with Prostheses
! E.g Hip Replacement. Below Knee Amputation
! Cases with special investigations
! E.g MRI/CT Scan
! Cases with special medications
! Chemotherapy
! Groupers do not have local costweights
! International Cost-weight international does not reflect
actual cost locally
! Tariff using uncustomised costweights are unstable
!
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Weaknesses of Current Case-
mix Groupers
! Logic of grouper difficult to be modfied when
coding rules changed
! Diagnosis ICD-11 from 2013 (Additional 7,800 codes Dx)
! Procedure ICHI from 2012 (WHO Procedural Classification)
! Severity level cannot be modified
! Severity level remains the same
! Depend on the private companies
! Source code held by vendor
UNU-CBG:
The New Casemix Grouper
! Grouper developed by researchers from United Nations
University
! UNU-International Institute For Global Health (Kuala Lumpur)
! UNU-International Institute For Software Technology (Macau)
! Research and Collaboration
! ITCC- International Training Centre on Case-Mix and Clinical Coding
! MOH of Developing Countries
! Asia Pacific Network of FIC
! WHO-FIC (ICD-10 and Procedure Classifications)
! Owned and Maintained by United Nations University
! United Nations University
! United Nations Agency
! Non-for Profit and No Commercial Interest
! Priority to support developing countries to achieve MDGs
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What is UNU-Case-Mix Grouper?
! Universal Grouper
! Cover all types of patients care
! Acute (In-patient/Outpatient)
! Sub-Acute (Moderately complex cases)
! Chronic Case (Long Stay Cases)
! Dynamic Grouper
! Total number of CBGs can be set-according to need of the country
! Severity level is not static
! Depending on types of patient care
! I to III
! I to IV
! I to IX
! I to X
! Very refined classifications
! Advance Grouper
! Can be used with future changes in diagnosis and procedure classifications (ICD-11
and ICHI classifications
EIGHT COMPONENTS OF UNU-CASEMIX
GROUPER
UNU-
GROUPER
ACUTE
SUB-ACUTE
CHRONIC
SPECIAL
PROCEDURES
SPECIAL
PROSTHESES
SPECIAL
DRUGS
SPECIAL
INVESTIGATIONS
Ambulatory
Package
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CASE-MIX MAIN GROUPS
(CMGs)
! CMGs are the first level of classifications
! Labels in Alphabet (A to Z)
! Mostly equivalent to Chapters in ICD-10
! Correspond to Body Systems and Payment Package
! 31 CMGs in UNU Grouper
! 22 Acute Care CMGs
! 2 Ambulatory CMGs
! 2 Subacute and Chronic CMGs
! 4 Special CMGs
! 1 Error CMGs
! Total DRGs (CBGs)= 1,220 (Range: 314-1,250)
Case-Based Groups (CBGs)
! Second level of classification
! Organised in 5 alpha-numeric code
! One letter and 4 numbers
! First Digit refers to CMG (Casemix Main Groups)
! Second Digit refer to Case-Type
! Third and Fourth Digit refer to specific DRG called
CBG
! Fifth Digit refer to severity level and resource
intensity level for specific package
! Consists of Medical/Surgical/Package Groups
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UNU-IIGH Case-Mix Grouper-
SERVICES COVERED
! Hospital In-patient
! Day Care Surgery
! Specialist Clinic
! Emergency Room
! General Out-patient
! Rehabilitation
! Chemotheraphy and
Radiotherapy
! Mental Health Services
and Procedures
! Chronic cases
! Long Staying
patients
! Specific Package
Groups
$ Package Out Patient
$ Prostheses
$ Drugs
$ Procedures
$ Investigations
UNU-IIGH CAPACITY BUILDING
PROGRAMME ON CASE-MIX
SYSTEM
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UNU-IIGH CAPACITY BUILDING
PROGRAMME ON CASE-MIX: The Benefits
! Softwares
! Digital Coding Tool-Data Tool Version 2.0
! UNU Case-mix CBG Grouper
! UNU-Code Assist Advance Coding Tool for Verifications
! Clinical Costing Software- Version 2.1
! Costing Template Software for Development of Hospital Base-Rates
! Costing Template Software for Development of National Tariff
! Access to DRG Logic of UNU Case-Mix Grouper
! MOH will have access to the UNU DRG Logic for future
development
! Training of MOH staff to use UNU DRG Logic for refinement of
casemix groupings
! Joint Development of Future Case-Mix Grouper
List of UNU-IIGH Training
Workshops ( Three Days)
! Workshop 1
! Introduction to Case-Mix
System
! Workshop 2
! Coding of Diagnosis and
Procedures for Case-Mix
! Workshop 3
! Installation and Maintenance of
UNU-IIGH Case-mix Software
! Workshop 4
! Case-mix Costing
! Workshop 5
! Clinical Pathways in Case-Mix
! Workshop 6
! Case-Mix Data Analysis
! Workshop 7
! Case-mix Costing Analysis
! Workshop 8
! Customisation of UNU-IIGH Case-
mix Software
! Workshop 9
! Development of Case-mix Tariff
For Provider Payment
! Workshop 10
! Presentation of Final Results and
National Roll-out
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Training and Installation
Manuals
UNU-IIGH Case-Mix On-line
Training Programme
! Free Introductory Course on Case-Mix
! Organised by UNU-IIGH and ITCC
! Online Registration open now
! Course started in August 2010
! http://unuiigh-casemixonline.org/
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http://unuiigh-casemixonline.org/
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UNU-IIGH Case-Mix Grouper
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Clinical Costing Software
Countries working with UNU-
IIGH on Casemix
! Asia
! Indonesia
! Philippines
! Mongolia
! Vietnam
! Malaysia
! Middle East
! Yemen
! United Arab Emirates
! Saudi Arabia
! South America
! Uruguay
! Chile
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Conclusion
! Casemix system is an important tool to ensure sustainability of
social health financing programme
! Lack of capacity and inaccessibility to low cost but reliable
groupers are two major obstacles in case-mix implementation
! Most commercial groupers are costly and cannot be customised to
meet needs of developing countries
! UNU-CBG Case-mix Grouper: Universal, Dynamic and Advance
Grouper specially developed to support implementation of case-mix
system in developing countries
! UNU-IIGH offer a complete package (capacity development/
softwares) to facilitate implementation of case-mix system for in
developing countries

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