Diagnostic related groupings Diagnosis related groupings (DRGS) are standard groupings of diseases that are clinically similar,

have comparable treatments or operations and use similar healthcare resources. They are a measure of the case mix in a health facility. Case Mix A Case MIX (CM) is the related frequency of admissions of various types of patients, reflecting needs for hospital resources or the distribution of in-patient cases treated by a hospital as classified by patient illness characteristics and treatment processes. Health facilities have patients with many different diagnoses and severity of illness and who use different services. Thus, there is a case mix, which differs from health facility to health facility. Measurement of case mix There are many ways of measuring case mix, some based on patients diagnoses or the severity of their illnesses, some on the utilization of services and some on the characteristics of the hospital or area in which it is located. CM measures or patient classification systems (PCS) are standard groupings of clinically similar treatments that use comparable levels of healthcare resource. There are ways of relating the types and complexities of patients a hospital treats to the resources utilized by the hospital based on the diagnosis, the treatment and the procedure carried out. An examination of several case-mix measures for their validity and acceptability in a per-case payment system reveals DRGSs to be the best available measure. They are mostly groups of International Classification of Diseases (ICD-10) Diagnoses and procedures that

have similar resource implications. The thousand and over ICD code is thereby reduced to a manageable number. The DRG is produced by grouping the 10,000+ ICD codes into a more manageable number of meaningful patient categories. Patients within each category are similar clinically and in terms of resource use. Each patient is assigned a DRG in a database. DRG assignment is made by DRG grouper software which uses principal diagnosis, secondary diagnoses surgical procedures, age, sex and discharge status of the patients treated (DRG Definitions Manual, 1994) to assign in-patient records to a specific DRG. The grouper requires that diagnoses and procedures be classified using ICD-10. The tariff a. Services covered by the Tariff The National Health Insurance Scheme (NHIS) Tariff is payable to all healthcare providers (HCPS) registered with the NHIS across the country. These include communitybased Health Planning and services (CHIPS), Health centres, District Hospital, Polyclinics or Sub-metro Hospitals, Quasi-Government Hospitals, Private Hospitals, Clinics and Maternity Homes, Regional hospitals and Teaching Hospitals. The tariff covers outpatient services, in-patient services, ancillary services such as physiotherapy and catering, and diagnostic services. It covers healthcare specialized areas such as child Health (paediatrics), General Adult Surgery, paediatric surgery, Ear and Throat, Orthopaedics, Accidents and Emergencies, General (Adult) Medicine, Maternal services, Gynaecology, Maxillo-facial dental care and Eye care. It also includes surgical operations, medical diagnostic and therapeutic procedures. b. Services not covered by the tariff

The tariff does not include all those conditions and services in the exclusive list. The tariff does not include costs of drugs, direct, indirect and overhead costs of pharmacy and any other costs related to drugs/medicines. It, however, includes costs of equipment and consumables used to administer drugs such as syringes, syringe pump, infusion burettes, needles cannula, etc. as these are consumables used directly in patient care. Patient transport services are not included in the present tariff. Thus, ambulance transport from one (HCPS) Healthcare Providers to another on referral is not presently covered. Accessing healthcare services under NHIS c. Gate keeper principle The tariff is determined based on the level of services provision known as the gate keeper principle or system. The tariff that should be reimbursed to health facility reflects the level and position as well as specialty and availability of services in each health facility. Patient bill is supposed to be refunded to health facility based on the following processes. The patient first point of attendance, except in the cases of emergency, shall be a primary healthcare facility, which includes community-based Health Planning and Service (CHPS), Health Centres, District Hospitals, Quasi-Government Hospitals, Private Hospitals, clinics and Maternity Homes. In localities where the only health facility is a Regional Hospital, the general outpatient department shall be considered a primary healthcare facility. This means that, health services provided by Regional Hospital at the out-patient Department will attract a primary healthcare facility tariff which is lower than the tariff for the Regional Hospital. Regional Hospitals are allowed to recover full regional tariff, when the patient is referred from the

primary healthcare facility. In other words, a full refund of health service bill should be made to health facility when the gate keeper system / process is completed. All healthcare services provided in these facilities are paid for by the District Mutual Health Insurance Schemes (DMHIS). All Services provided for by Tema General Hospital are paid for by Tema Metropolitan Mutual Health Insurance Scheme. Even though the National Health Insurance Scheme is decentralized on District, Municipal and Metropolitan bases, Tema General Hospital provides services to all clients of the various schemes all over the country and paid by Tema Metropolitan Mutual Health Insurance Scheme. These payments are offset when the National Health Insurance Authority is disbursing funds from the Value Add Tax (VAT) and Social Security and National Insurance Trust (SSNIT). In case where the services are not available, all referred cases other than those in the Exclusion list are paid for by DMHIS. Emergencies are attended to at any health facility without regard to the gate keeper system. A gatekeeper principle is therefore followed which means that the scheme is accessed only through the primary care level, that is health services at the district level, and access to the higher levels is by referral from the primary and other appropriate levels. The level of care therefore determines the type of services provided for each specialty and the fees charged. Healthcare providers are reimbursed only for the services they provide which are listed for their levels. The National Health Authority (NHIA) believes that, strict adherence to this principle is important and beneficial for all patients, Healthcare providers (HCPS) and the National Health Insurance Scheme (NHIS).

Regional and Teaching hospitals concentrate on the more complex diseases and reduce the over crowding that occurs at their premises and therefore improve quality of care. Goal of the g-rdgs tarrifs THE National Health Insurance Authority believes that, this payment methodology present a better understanding to both Ghana Health Service (GHS) and National Health Insurance Authority (NHIA). a. It provides reimbursement for full costs of services rendered. b. It gives healthcare providers incentive to provide services efficiently. Full payment means HCPS retain all the benefits of increased efficiency, although they bear the burden if costs are above payment rates. c. It makes payment more predictable, understandable and simpler for HCPS and District Mutual Scheme Managers to the greatest extent possible. d. It increases fairness among HCPS by paying them similar amounts for similar services. Tarrif structure Table 1. The tariff structure is shown below. Unit/ Currency Admission spell Illness Episode- Attendance

Tariffs for: Tariff for: All Admissions All OPD attendance by specialty All inclusive bundled for all services provided to One tariff for new and inpatients. follow-ups Day case and in patient All inclusive bundled procedures combined tariff Different tariff for children Unbundled tariff for and adult health facilities that do not provide all services. Different tariff for children and adults Source: Originally from National Health Insurance Scheme Tariff and Benefits package Operation Manual (2008) The tariff is made up of the estimated direct and indirect costs of providing the various services to each patient depending on the patients G-DRGS and the level of care. The tariff and level of healtcare The tariff structure recognizes the different levels of care in Ghana: Primary, Secondary and Tertiary levels. The tariffs are graduated from the lowest to the highest level. This graduation is mainly due to the increase in indirect and overhead costs of Health care at higher levels.

The components of costs reimbursed by the tariff are summarized below: Total Direct care cost Indirect and Overhead cost

Direct care Investigation Anaesthesia Costs Cost Costs

Total Indirect Catering and Overhead Costs Costs

Consumables: Ward Theatre Recovery Procedure Unit

Consumables: Reagents Stains General consumables X-rays Specimen containers Human Resource

Consumables Theatre Drugs

Figure 2. Vehicle running and Food Maintenance Materials Utilities Administration House keeping Capital and equipment cost Maintenance of building and equipment Human resource Human Resource

Human Resource

Human Resource

The components of the tariff Source: Originally from National Health Insurance Scheme Tariff and Benefits package Operation Manual (2008)

Analysis of cost for treatment The direct cost (DCs) are those costs incurred in providing direct service to the patient depending on the diagnosis and/or procedure (i.e. the G-DRG).The DCs consist of: Human resource costs. The man hours of medical, nursing, and other staff needed to directly provide the services. It includes, for example, the costs of a laboratory technician working on blood or other tissue sample, the nurses assisting in an operation in the theatre, wards,, etc., and the doctors consultation, examination and

theatre operation. All the above mentioned man hours are factored into determining the tariff for a patient/client who may be suffering from one or more of the medical conditions. The tariff does not take into consideration the material for example the cost of the reagents and their types that will be needed by the laboratory technician, x-ray technician or any investigative staff. It came to light that, the complexitys of the condition of a client/patient, the higher the cost of investigation of the condition. The material/ reagents or x-ray frame needed to conduct the investigations was determined without considering the changing cost of the investigative materials. Prices of investigative materials have changed since 2004, when the NHIS started operation. Consumables and other disposable costs. These are the costs of items used in the direct care of the patient. They include gloves, syringes, etc., laboratory reagents and stains and diagnostic imaging consumables such as x-rays, barium meal, etc. For anaesthesia, this also includes all anaesthetic drugs and infusions, including blood transfusion, used during and after operation. It was established by the researcher that, that anaesthestic drugs which is purchased as a drug was combined with consumables. The determination of how much anaesthestic drug would be needed for a particular condition or procedure was not considered. The fact that drugs are separately billed makes the combination incorrect and does not follow the logic that established the NHIS, which states that drugs must be separately billed. Another inconsistency is the fact that, blood transfusion is consolidated with consumables without factoring in the processing cost, which is made-up of important reagents that are used in ensuring that, the blood is safe to be transfused or given to a patient or client.

The claim by the NHIA that direct costs (DCS) are incurred in the following areas needed to be analyzed. The assumption that Government of Ghana (GOG) take care of all indirect costs may hold in the light of the fact that all public resources belong to Government, but it is also true that Government is limited in providing the necessary needs of public health institutions to enable them provide quality health service to patient/client. Therefore, there is the need to decouple every cost in the health delivery system to enable the management of public health facility Provide the necessary health provision resource for health service provider to give quality health service to patient/client. The direct costs (DCs) are incurred at the following areas: i. ii. iii. Outpatients department (OPD) Wards Various Diagnostic services- Pathology, Haematology, bacteriology, blood bank/ transfusion, imaging diagnostics etc. Note that mortuary and post-mortem services are not included. iv. Theatre and recovery wards, intensive care units, neonatal intensive care units and high Dependency units v. Other procedures or investigation units such as-endoscopy suites, treatment and ressing rooms, procedure rooms, ECG, EEG, hearing tests etc. The type and number of diagnostic test for each patient on admission are taken into account for each G-DRG. These were determined based on the National Treatment

Guidelines expert opinion of good medical practice. For example, a patient with Acute Renal Failure without dialysis (G-DRG) on a medical ward (at levels D- Regional Hospital or ETertiary Hospital or Teaching Hospital) is costed to have a basic medical investigation package of full blood count, blood urea, electrolytes and creatinine (BUE&Cr), liver function test, chest x-ray, routine urine examination, abdominal and pelvic ultrasound, plus 3 repeat BUE&Cr to monitor progress. Change in the cost of the reagents was not factored in the determination of inpatient G-DRGs tariffs. The numbers of times that the test will be conducted were determined taking into consideration the number of days that the patient or client will spend in the hospital. The tariff requires Doctors to discharge patients/clients or transfer to the higher health facility if they spend longer days in hospital. This does not enable health providers to give quality health services to patients/ clients. When health providers look at the tariffs and the services that a patient/client might have received, if even they can do more, due to limitation of resources and for the fact that public health facility depends heavily on (IGF) internal generated fund will rather transfer or discharge if the patient could be managed at home or the higher facility. Indirect costs are those which cannot be attributable to a particular patient but can be shared by a number of patients. Examples are: house keeping costs of cleaning a ward, laundry, materials such as thermometers etc used for all patients etc. Overhead costs are the costs of running and maintaining the health facility or unit/department thereof. They include human resource costs, vehicle running and maintenance costs, utilities, planning, administration, finance and the general maintenance of building, grounds and the cost of capital (rent, new building or building replacement costs) and equipment.

The total overhead and indirect cost is made up of the sum of the indirect and overhead costs of service areas utilised in providing service for the particular G-DRG. Examples of service areas for teaching hospitals are: Service Areas Accident & Emergency Accident & Emergency Theatre Blood Transfusion Service Laboratory Medical Wards Obstetrics & Gynaecology Theatre Obstetrics & Gynaecology Wards OPD, Dental OPD, ENT OPD, Eye OPD, Medicine OPD, Obstetrics & Gynaecology OPD, Paediatric OPD, Surgery Paediatric Wards Physiotherapy Radiology Surgical Theatre Surgical Wards For example, the total indirect and overhead cost for G-DRG MEDI18, Ischaemic Heart disease, admitted on the medical ward is made up of the indirect and overhead costs of:

Service Areas Medical Wards Laboratory Radiology Those for G-DRG ASUR01, Operations of thyroid and parathyroid glands, are:

Service Areas Surgical Wards Laboratory Blood Transfusion Radiology Surgical Theatre The indirect and overhead costs for each service area are a product of the frequency of use of that service area (average length of stay for wards, number of sessions of treatment for physiotherapy and number of investigations for diagnostic services) and the unit cost for that service area. Catering Catering is not provided by all (HCPs) Health Care Providers. Thus, catering costs is only reimbursed to those HCPs that provide catering. For each level of health care there is therefore one tariff inclusive and another exclusive of catering.

Availability and Use of Diagnostic Service The tariff took into consideration the availability of diagnostic services at each level of healthcare; higher levels of health care have in general more facilities for investigations than lower levels. For example, a patient with cerebro-vascular accident (G-DRG MEDI14)

will not have a CT scan from level C (District Hospital-Tema General Hospital ) while this might be available at the Teaching Hospital (level E). The tariff also took into consideration that not all patients with the same G-DRG will have or be provided with certain investigations. For example, not all cerebro-vascular accidents at the teaching hospital will undergo a CT scan. However, in line with good medical practice, certain basic investigative procedures, depending on the specialty or (MDC) Major Diagnosis Catergory, were costed for each hospital spell or illness episode. For example, all surgical patients who undergo surgery under general anaesthesia (GA) are costed for a basic investigation package required for GA. On top of this basic package are costs for investigations needed to diagnose the particular disease and to monitor progress pre- and post-operatively. Tariffs for (HCPs) Healthcare providers without diagnostic facilities Most of the tariffs are inclusive of all necessary services provided in one facility. However, there are many HCPs that do not provide any or provide some diagnostic services. This means that such HCPs refer patients to other HCPs for such services. The tariff has considered this by unbundling the costs of such diagnostic services from the all-inclusive tariff. For example, tissue histology is not done at any district hospital but are sent to regional or teachings hospitals, therefore tissue histology is removed from the tariff for those G-DRGs that need it at District and lower levels. HCPs that do not provide all services are mostly those at the district and health centre levels including (CHPS) community health providers compounds, maternity homes and private practitioners. For these HCPs GDRGs for outpatient consultations unbundled from investigations and other services have been determined. G-DRGs for diagnostic services have been set up for those HCPs which provide these services for other HCPs. Thus, while the total cost of providing the complete management for

a particular G-DRG is the same, the reimbursement is split between two HCPs, the one providing the care and the other providing the diagnostic services. Thus, for example, a patient with stroke may be cared for at a District Hospital and be referred to a Teaching Hospital for a CT scan. The Scheme will reimburse the District Hospital for the care of the patient through the tariff which does not include a CT and will reimburse the Teaching hospital by the CT Scan G-DRG. Where a HCP, which was providing the all-inclusive bundled service, is temporarily not able to do so and therefore refers insured patients to another HCP for that service, special local arrangements for reimbursement have to be made between that HCP, the District Scheme and the other HCP now providing the service. For example, HCP1 cannot provide xray services it had been providing because its machine has broken down and it sends its patients to HCP2. The District Scheme and the two HCPs should agree on arrangements for reimbursement. That arrangement, however, will depend on whether the second HCP was also contracted to provide service by the Scheme. If HCP2 was contracted to provide service, the Scheme could reimburse HCP1 with the OPD tariff less the unbundled investigation tariff (in this example that for x-ray) and reimburse HCP2 with that unbundled investigation tariff. If HCP2 is not contracted with the Scheme, then the Scheme is not legally able to deal directly with that HCP. HCP1 should therefore arrange with HCP2 (contract-out arrangements) to pay it for the service while claiming the all-inclusive bundled tariff from the Scheme. It is important that in all such situations: The District Mutual Insurance Scheme be informed and agreement obtained as soon as this situation occurs

Insured patients are not put in the position of paying for services which HCP has been contracted to provide. To prevent double claims by HCPs, Scheme managers should, at the onset of the

contract, agree with HCPs, based on the report of the accreditation committee, which of the two tariffs should apply for each HCP. No one HCP should claim for the all-inclusive bundle tariff and the tariff for diagnostic service for the same patient. Furthermore, patients referred for diagnostic service should not be treated as if they had in addition been provided other services. The HCP should claim only for the diagnostic G-DRG and not others, such as OPD. This would then break the fundamental rule that each patient should have only one G-DRG. Government support to healthcare providers and the tariff The tariff recognizes the differential Government support to various HCPs. The tariff reimburses the full cost of service provision for those HCPs that do not have any Government of Ghana (GOG) support and for those that have GOG support, the full costs less of that support.HCPs that have GOG support are: All public health facilities under the MOH (Ghana Health Service and Teaching Hospitals) of which Tema General Hospital is classified. (CHAG) Christian Health Association of Ghana hospitals, health centres and clinics Quasi-Government health institutions

For the HCPs supported by GOG, the tariff does not include the following:

HCP GHS and Teaching Hospitals: HR CHAG health facilities: HR Quasi-Government health facilities* HR on IGF is included in tariff. roll.

Cost not included in tariff All Human Resource (HR) on GOG pay roll. on IGF is included in tariff Capital and equipment costs All Human Resource (HR) on GOG pay roll. on IGF is included in tariff. All Human Resource (HR) on GOG pay

Capital and Equipment costs

* There seems to be two sub-groups of institutions in this group: one that is owned by and part financed by the GOG and another one that is publicly owned or partly owned by the state but do not receive direct support for the GOG.

Outpatients Tariff General The Outpatients (OPD) tariff is an all-inclusive bundled payment per visit for OPD services provided to the patient including laboratory, imaging, and other diagnostics, supplies, physiotherapy, equipment, human resource and any other input in the OPD. The tariff does not differentiate new from follow up cases, nor specialist from general OPD at regional and district hospitals . This is to ensure simplicity and ease of processing claims. The OPD tariff was determined in the same way as the in-patient tariff using the GDRGs grouping for the common outpatient attendances in the country. The direct and indirect costs for each G-DRG were determined and a weighted average for each specialty (MDC)

was calculated to set the OPD tariff. Thus, there is one tariff for OPD attendances for each specialty at teaching hospitals. For regional hospitals, district hospitals and health centres all the cases, except dental, eye and ENT, were put together and a weighted average determined to produce one general tariff for each level. These were done because at the regional and lower levels the same OPD facilities and the same mix of health personnel are used for both the specialist and general OPDs. The costs were, not surprisingly, the same. On the other hand, all OPD services at the teaching hospitals are specialized and held in separate departments. Similarly, Eye, Dental and ENT services are mainly provided separately at all levels. For the same reasons as above, no significant differences in the costs of OPD services for children and adults were found at regional and lower levels. The OPD tariff is therefore the same for children and adults at regional and lower levels. Health Episodes The basic currency or unit of the OPD tariff is the ill health episode. This is the period of time in which the patient is regarded as ill until he is declared healed. Ill health episode is easy to understand in the case of acute illnesses, such as malaria, in which health services are sought in episodes of ill health, that is, whenever the patient is sick, for the illness episode ends within a certain time. Access to the health services takes place within that time. The period of ill health when health services are rendered is the ill health episode. During the ill health episode the patient makes an initial consultation at which he/she is assessed, certain investigations are requested and treatment may be initiated. The patient is asked to report for review consultation(s), for assessment of the treatment and/or to report back with results of investigations. An ill health episode therefore consists of an initial consultation and review consultation(s).

To ensure good quality of care, the committee of experts suggested that the ill health episode should consist of an initial visit and two review visits within two weeks. At the first visit, clinical assessment is made, a working diagnosis is made and investigations requested. The second visit is for review of the investigations and review of the diagnosis. The third visit is for evaluation of treatment. The total costs of providing this ill health episode was computed for each G-DRG and the weighted average found for the MDC groupings at the teaching hospitals and for all cases except antenatal, dental, ENT and ophthalmology (EYE), at the regional, district and health centre levels. These ill health episodes costs are reimbursed by a tariff which should be claimed as one lump sum at the end of the illness episode. To ensure that this lump sum is paid out for the actual patient visits, the total ill health episode tariff is divided equally into 3 parts according to the expected maximum number of OPD attendances. If a patient only attends 2 OPD sessions during the two weeks, only two-thirds of the total tariff is reimbursed; if the patient attends 3 OPD clinics, then, the full tariff is provided.

Acute Illness OPD attendance According to the present tariff structure, only a maximum of two (2) reviews within two (2) weeks of the first consultation are allowed and will be reimbursed. Thus, for acute illnesses a maximum of three (3) visits will be reimbursed over the two weeks. If after the two-week period the same patient presents with the same or other illness, he/she has restarted another ill health episode. If, however, it is the HCP that schedules an OPD attendance beyond two weeks of the first attendance for the same illness then this is outside the ill health episode and that OPD attendance/visit should therefore not be reimbursed.

Claim for acute illness OPD attendance should be made after the illness episode, that is after 2 weeks of the first attendance. HCPs should make internal arrangements to ensure that they have all records to fill in the claim form at the end of that period.

Chronic Illness OPD Attendance For patients with chronic illnesses/conditions such as diabetes, hypertension, epilepsy, chronic asthma, etc., the follow up period does not end. For such patients who usually attend specialist clinics and are given follow up appointments, the tariff expert committee has recommended that a maximum of six (6) OPD visits (inclusive of the first visit) within 12 months of the first visit should be reimbursed. For patients with acute illnesses the tariff allows for a maximum of three visits within two weeks. For patients with chronic illnesses the tariff allows for a maximum of Six (6) visits within each year. Claim for reimbursement for chronic OPD attendance can be made after each OPD attendance. If a patient with a chronic illness presents with another ill health problem, he/she has a different illness episode and reimbursement should be claimed as such. Thus, for example, a patient who has a chronic condition such as diabetes and visits for the first time makes an initial consultation, subsequent consultations arranged by the health facility for follow up of his/her diabetic condition are follow-up or review consultations up to a maximum total of six visits in twelve months. If, however, the diabetic patient has a complication of his/her original disease or has other disease such as malaria, and makes a self initiated consultation, this new consultation begins a new illness episode of the acute illness type a maximum of 3 visits in two weeks in addition to the chronic illness follow up visits remaining. If the follow-up visit falls within the two week acute illness episode that chronic

follow-up visit is counted as part of the 3 visits for the illness episode and is therefore not to be reimbursed as extra. Antenatal OPD attendance Antenatal attendance provides a special situation; it occurs over a longer period but less than a year. Reimbursement is for a maximum of four (4) visits per each pregnancy. Claim for reimbursement can be made after each antenatal visit. As in the case of chronic illness OPD attendance, if a pregnant woman attends antenatal visit because of an acute problem, related or not related to her pregnancy, outside of her scheduled antenatal appointment, she has made an acute illness episode visit and has initiated an acute illness episode. Reimbursement for that episode should be managed as for an acute illness episode in a patient who has chronic illness as above.

Surgical patients OPD attendance Patients with elective surgical conditions are usually seen at the OPD and, after the initial consultation, are given follow up visits for assessment of the investigations and then are placed on waiting list until surgery. In order to reduce the waiting list time and also not to pay for unnecessary OPD attendances, the expert committee recommended a maximum of four (4) OPD visits (inclusive of the first visit) within twelve months from the date of the first visit.

In-patients discharged to OPD The concept of ill health episode also applies to patients who were originally on admission and were discharged and reviewed at the OPD. If the condition for admission was an acute one, such as caesarean section, acute appendicitis, pneumonia, etc., then a maximum of three (3) review consultations over a maximum of six (6) weeks will be reimbursed. If the

condition for admission was a chronic one, such as chronic osteomyelitis, thyroidectomy, renal failure etc., post discharge consultations related to the disease should be billed for a maximum of six (6) visits per each twelve months.

Detention for observation A tariff for short stay (detention for observation and treatment) is set for health facilities, such as health centres, clinics and maternity homes, where admission facilities are not available and for other health facilities where patients are detained for observation for not more than 24 hours or overnight.

Accident and emergency and casualty consultations Accident and Emergency and casualties have three groups of patients. Claims for these are to be made according to the table below:

Emergency Patient Groups 1. Managed similar to OPD 2. Detained for less than 24 hours

Tariff Use OPD tariff (G-DRG appropriate for level) Use Detention for Observation tariff (G-DRG Appropriate for level)

3. Admitted.

Use In-patient G-DRG (G-DRG appropriate for level)

Multiple specialty OPD attendances Some patients may be seen on one day during the same illness episode by more than one Specialist. This may occur because the initial referral may be wrong, the initial specialist may refer the patient for an opinion or the patient may have more than one illness. For

simplicity and to avoid internal referral to higher costing specialties for double reimbursement, such multiple specialty OPD attendances on one day during each illness episode should be recorded as one outpatient visit and paid at the tariff for the highest cost specialty.

Outpatient transfers Transfers or referrals from OPD will be reimbursed for maximum of two (2) OPD attendances. It is the experts view that by the second visit enough evidence would have been obtained to arrive at the decision to refer. Outpatients Procedures Outpatient procedures are included in the G-DRG tariff for their respective MDCs. Note that if an OPD procedure is performed as an inpatient procedure reimbursement will still be as an outpatient. On the other hand, if an inpatient procedure is performed as an outpatient one, the inpatient tariff will still be reimbursed, resulting in cost saving for the HCP. Providers should note the readmission rule.

In-Patients Tariff Unit/Currency The tariff for admitted patients is based on the spell of admission to discharge, transfer out or death for each patient. This is the basic currency or unit for the inpatient tariff. Claim for reimbursement can only be made after discharge, transfer out or death of the patient. For inpatients, the tariff is made up of an all-inclusive bundle of direct and indirect costs of providing the full range of services to each patient during their spell for each G-DRG on the wards.

Each patient is given one G-DRG based on the procedure or the principal diagnosis and this is used to reimburse the HCP

Emergency readmission In principle, emergency readmission of patients with the same or related diagnosis should not attract reimbursement if it was due to the HCP not providing sufficient quality of service or preparing the patient adequately for discharge. No reimbursement for emergency readmission should be provided if: The readmission is to the same HCP, and The readmission is within 14 days of discharge The duration of the previous admission was less than one and half (1.5) times the average LOS for the G-DRG. Reimbursement at the G-DRG rate is provided for all other cases of readmission.

Inpatient transfer out To encourage good medical practice of early referral and to prevent dumping of cases to other HCPs while claiming full G-DRG tariff, a tariff for referred cases has been determined. This tariff is based on minimal investigations and procedures needed to make a diagnosis and adequate time for first aid treatment and assessment to arrive at the decision to refer. The tariff is based on a time that is less than the average LOS for the G-DRG and is therefore less than the full tariff for that G-DRG.

Admission through accident and emergency and outpatient wards

Attendance at Accident and Emergency or OPD and subsequent admission on another day should be reimbursed at the usual OPD rate. If however, admission occurs on the same day of A&E or OPD attendance, then the in-patient G-DRG tariff should be applied. Multiple procedures in one admission spell When more than one procedures are recorded for a patient, the procedure with the highest tariff is used to assign the G-DRG. This is in keeping with the cardinal rule that only one G-DRG is assigned to each spell. Example: 19 year old young man admitted and operated for typhoid perforation. He was then dialysed for acute renal failure. His possible G-DRGs are: Diagnosis G-DRG TARIFF* Typhoid perforation Laparotomy for peritonitis GH 350 Acute renal failure complicating any condition Acute Renal failure with dialysis 12 yrs GH 850 * These figures are illustrative only and may not be the true values. The acute renal failure with dialysis G-DRG is the dominant one and should therefore be recorded and used to claim for payment.

Multiple diagnoses, complications and comorbidity The tariff emphasises simplicity. It is therefore not flexible enough to be split into varying severity and complexity levels within each G-DRG. As above, where there are more than one diagnoses and therefore more than one possible G-DRG, the dominant (highest cost) diagnosis should be used to assign the single G-DRG. If a complication necessitates an operative procedure then according to the G-DRG algorithm the operative procedure should be used to assign the G-DRG.

Code structure for G-DRG The G-DRG uses seven alpha-numeric code structure in the format: AAAANNA. The first 4 characters are alphabets (A) and represent the Major Diagnostic categories( MDC) or specialty (e.g. OBGY = Obstetrics and Gynaecology). The next two characters are numbers (N) and represent the number of the G-DRG within the MDC. The last character, which is an alphabet (A), is for any split for the GDRG, e.g. age groups. The code structure is represented below:

MDC G-DRG No. Split AAAA NN A MDC The G-DRG consists of the following MDCs:

MDC Description ASUR- Adult Surgery DENT- Dental and Maxillofacial Surgery ENTH- Ear Nose and Throat Surgery INVE- Investigations MEDI- Medicine OBGY- Obstetrics and Gynaecology OPDC -OPD Consultation OPHT- Ophthalmology ORTH- Orthopaedics PAED- Paediatrics PSUR- Paediatric Surgery

RSUR -Reconstructive surgery ZOOM- Cross-MDC G-DRG- No. Two numeric codes which identifies the G-DRG in the MDC.Split Each G-DRG is split by a code for age. Patients aged 12 years have an ending code of A and those <12 years that code is C. Coding definitions Primary procedure The primary procedure is that procedure which uses the greatest resources. Principal diagnosis or main problem The Principal Diagnosis (PD) or main problem is the problem that is recognised to be the clinically significant reason for the patients visit or admission and which determines the consultation and treatment or management. The Principal diagnosis is assigned by the health care provider at the end of the admission spell or illness episode for OPD visits. This is provided by the clinician (doctor, medical assistant, midwife or other front line practitioner) responsible for the care of the patient. When multiple diagnoses are considered as the reason for the care, the principle diagnosis is that which is responsible for the greatest use of resources.

Other diagnoses or problems Other diagnoses or problems are conditions, circumstances or problems which coexist at the time of visit or consultation or develop during admission, which influence the patients need for treatment or care. A total of 3 other diagnoses Chronic illness and/or conditions previously treated and which no longer exist are not to be regarded as other

diagnoses. For example, for a patient who had asthma as a child and has an inguinal hernia operation, the asthma, which no longer exists, should not be recorded as other diagnosis. However, there are certain chronic illnesses such as diabetes that must always be coded even if they are not being treated during the present episode of care.

How to determine the G-DRG and tariff This section will enable you to determine the G-DRG from a given set of diagnosis/procedure information in the patient notes/folder. The determination of the G-DRG starts right from the first encounter with the patient/client at the records department and continues after the end of the spell or illness episode. It is important that all health personnel realise and play their roles properly. Indeed, all health personnel are involved directly or indirectly in the coding and determination of the G-DRG. The biodata: name, age, sex, address should be properly entered into the notes. The date of admission and discharge or end of illness episode should be clearly recorded.

Determine the G-DRG For each patient spell or illness episode one G-DRG has to be determined to arrive at the tariff.

Record diagnosis(es) and procedure(s) a. Clinicians should clearly record the diagnosis(es) and procedure(s), if any was/were performed, during the spell or illness episode. b. At the end of patients spell in hospital (that is, after patients discharge) or illness episode (that is, at the end of two weeks for acute illness episode or at the end of each

chronic follow-up OPD attendance), the biostatistician or other health personnel should review the patients notes and extract the diagnosis(es) and procedure(s) performed.

Determine the (ICD-10) International classification of disease code The next step is to determine the ICD-10 code. This can be done by the records department from the ICD-10 code book or computer programme available in the health facility. You can also use the Code to Group tables provided. The Code to Group Table ( ANNEX C) shows the relationship between the underlying patient diagnosis, ICD- 10 code, procedures and the appropriate core G-DRG. It is to enable you to quickly locate individual ICD-10 codes and to identify the core G-DRG to which they are assigned. Even though a grouper software will eventually be used to perform this function in the future, you still need to know and understand this procedure and logic, for a better use of the system. a. Which specialty looked after the patient? Use the specialty which looked after the patient to help you look at the appropriate table. For example, if the patient was seen at the ENT clinic then use the ENT Code to Group Table. b. Look at the column with the list of diagnoses and find the nearest diagnosis in that list to what is written in the notes. Find the appropriate ICD-10 code for that diagnosis from the same row in the ICD-10 code column. Repeat this for all the diagnoses in the records. Determine the core G-DRG. The core G-DRG is primarily determined by the dominant procedure or the principal diagnosis. Each patient can have only one G-DRG. If a procedure was performed then this will determine the G-DRG. Therefore in this step answer the question: Was a procedure performed?

a.

Yes procedure was performed If a procedure was performed use the dominant procedure to determine the G-DRG. Look at the column containing the list of procedures in the tables for the surgical specialties for the procedure(s) performed. Look at the G-DRG column for the core G-DRG that corresponds to the row you found the name of procedure. If more than one procedure was performed then repeat the step until you have found

all the core G-DRGs. b. Procedure not performed. If a procedure was not performed then use the principal or main diagnosis to determine the G-DRG. Look at the column containing the list of diagnoses and find the row that contains the principal diagnosis. Find the corresponding G-DRG in the column of GDRGs for the principal diagnosis. If there is more than one diagnosis then repeat the step until you have found all the core G-DRGs. Determine the final G-DRG All G-DRGs are split by age into two child and adult. Having determined the core G-DRG use the Ghana DRGs Table (see ANNEX D) to find the final G-DRG. a. Find the name of the G-DRG in the appropriate column. You may find that in some tables there are 2 rows with the same G-DRG name. Which row you chose is determined by the age of the patient. Is the patient less than 12 years old? b. If the age of the patient is less than 12 years then look at the G-DRG column for the core G-DRG that you have previously determined and find the one that ends with C. this is the final G-DRG. c. If the patient is 12 years or more then look for the G-DRG with the same core GDRG but ends with A. This is the final G-DRG for the patient.

Determine the tariff Having determined the G-DRG it is easy to arrive at the tariff. Look at the G-DRG to Tariff table for your health facilitys level of health care, find the G-DRG and one the same row find the tariff that corresponds to it for your level of health institution.

Instructions for completion of claim forms There is one claim form to be used by all HCPs even if they provide all or part of health services to a client or patient. If the health care provider only provided drugs, diagnostic services or the all-inclusive service at OPD or on the wards, the HCP should fill the various relevant aspects of the one claim form. The Claim Form is shown in page 114. The number of the points below corresponds to the numbers on the form. Claim for reimbursement shall include: 1. The Health Institution (HI) name and HI Code this should be pre-printed for each HCP and no entry is required. 2. 3. Claim number This should be a pre-printed information and no entry is required. Clients Surname and other names Complete in full. Ensure that the names match those on clients NHIS ID card 4. 5. Clients sex Enter as M or F. Clients date of birth. If available. Ensure that this matches those on patients NHIS ID card. 6. 7. Clients age - This is important especially when client does not remember birth date. Clients NHIS Registration number ensure that this is accurately recorded.

8.

Hospital Record number This is important to track the folder or hospital record. The hospital or folder or OPD card number should be accurately copied here.

9. a.

Type of Service this is to be filled in by all HCPs. Tick the type of service provided to client: Outpatient, Inpatient, Diagnostic or Pharmacy. Note that In-patient, Outpatient and Investigation services are mutually exclusive for any one HCP. That is, you cannot claim for those services together for the same client. Therefore tick only one out of the three in that box.

b.

Tick if an all-inclusive or unbundled service has been provided to client. If you provided only OPD or in-patient service and the diagnostic services were done outside of your facility then tick unbundled service. If you provided care and investigations in the health facility for this patient then tick All-inclusive service.

10.

Dates of service provision Enter date(s) when service(s) was/were provided. The first patient. The second date is the date of the second OPD visit or the date of discharge or outcome event recorded in number 12. Record the third and fourth visit dates if patient made those OPD visits. Note that for acute ill health episode a maximum of 3 OPD visits will be reimbursed. visit date is the first date of attendance at the OPD or date of admission of the

11.

Duration of Spell. Enter the number of days of the spell of admission, illness episode. For those admitted this is the duration of admission and is the difference between the recorded 1st Visit/Admission and the 2nd Visit/Discharge dates. For In-patient clients, this should be the difference between the first and up to the 3rd visit and cannot be more than 2 weeks.

12.

Outcome this is to indicate whether the client died, was discharged, transferred to another health institution or absconded/discharged against medical advice.

13.

Type of Attendance this is to indicate whether the patient initiated the hospital attendance or the health facility made an appointment. If the patient self referred or was referred by another health facility and came as an emergency or an acute ill health episode then tick Emergency/Acute episode. If your health facility made the appointment in a chronic follow-up such as in a diabetic clinic or antenatal clinic etc., then tick chronic follow-up.

14.

Specialty this helps you in determining the G-DRG. Indicate which specialty looked after the client. The choice is General, Adult surgery, Dental, ENT, Medical, Ophthalmology, Orthopaedics, Obstetrics and Gynaecology, Paediatrics, Paediatric surgery, Reconstructive surgery.

15.

Procedure If any procedure was/were performed enter the procedure(s). Enter the description of the procedure(s) performed as written in the code to group list (see ANNEX C), the date and the G-DRG. The description should verify the G-DRG. The date(s) should be within the dates of service provision filled above (see point 9 above).

16.

Diagnosis list the diagnosis(es) for which the patient sought the health service. List the Principal diagnosis or main problem first. Sequence the other diagnosis based on their impact on resources provided. For each diagnosis, look up and enter the ICD-10 code and the G-DRG. Every patient seen at an outpatient or inpatient should have at least one diagnosis filled otherwise the claim cannot be processed.

17.

Diagnostics fill in this section of the claim form only when your facility has provided diagnostic (laboratory and imaging) services unbundled from inpatient and outpatient services. Enter the description/name of the investigation, the date done and its GDRG.

18.

Medicines Enter the name of drug(s), the quantity prescribed and the date dispensed.

Enter also the code of each medicine. 19. Client Claim Summary this summarises the information in the form in this section. This section will ensure quick assessment of claims. The rule of thumb here is the rule of one. There can be only one entry in each column. There can be only one GDRG code for each patient and this code can be either an Inpatient, Outpatient code or Diagnostics. The G-DRG is that of the primary procedure or principal diagnosis Only one of cells A, B, or C can be filled. There can be only one pharmacy amount and only one total claim. 20. Signature Claim forms must bear the name and personal signature of the approved HCP officer. The officer must be delegated in the institution to coordinate the form filling. The form, can be filled by multiple personnel (such as records officers, biostatisticians, pharmacists, nurses, account clerks etc.) especially in large facilities. The responsible officer checks each form and ensures completeness. He/she then summaries all the claims, writes a cover letter to be reviewed and signed by the chief executive of the hospital/facility before onward transmission to the scheme office. Itemized billing As indicated above, itemized billing is the collection of various costs of resources that has been used on a client in a health facility to establish the bill of a client/ patient. It details out item by item used on patient without any assumption as to weather the patient actual received or use any item or medical resources. Currently Tema General Hospital is using itemized billing for uninsured client and the G-DRG for insured client/patients.

The itemized billing tariff is determined by the hospital management who considers the cost of medical resource in the market and fixed tariff that will recover cost incurred by the hospital or the resources used on the patient. The above procedures and diagnosis are selected from various specialists who consume more of medical resources. It is important to note that, all in-patient client consumable are higher than the G-DRGS charge by the national health insurance. Drugs/ medicine in both cases are not added to services. Every drug / medicine that is taken by a client/ patient is paid separately, except anesthesia drugs which were added to every procedure performed in the theatre. Determination of the itemized billing for out-patient/ clients a. Consultation 1. Patient folder 2. Patient identification card (I/D) 3. Claim form 4. Patient confirmation sheet 5. Investigations -X-ray Chest -ECG -FBC (Full blood count) -Scan (abdomen) Total cost 17.00 10.00 8.00 10.00 46.30 1.15 .05 . 05 .05

Determination of the itemized billing for in-patient a. Thyroidectomy GH 1. Gauze 2. pack 3. Sutures vicry 1 Plain Nylon 4. Corrugated drain 5. Surgical gloves 6. Examination gloves 7. Nelaton catheters, spirit, blade, cotton 8. Betadire / Lotion 9. Plaster 10. Miscellaneous 12.00 6.00 24.00 0.60 2.40 3.00 4.45 2.00 2.00 4.50 0.50 10.00

11. Anesthesia (Drug) 12. Procedure fee (Condition) 13. Maintenance of monitor 14. Electricity 15. Water Total b. Surgical hernia 1. 2. Gauze Sutures vicry (30) (3)

100.00 200.00 2.00 1.5 1.00 375.95

6.00 12.90 1.80 0.60 2.00 4.50 3.70 2.00 5.00 100.00

Sutures Nylon (3) Sutures plain 3. (1)

Scapel blade, Cotton, spirit Lotion/ Betadire

4. 5. 6. 7.

Surgical gloves Examination gloves Miscellaneous Procedure fee (Condition)

13. 14. 15. Total

Maintenance of monitor Electricity Water

2.00 1.5 1.00 143.00

C. Hernia with anaesthesia Maintenance of monitor Anaesthesia Total d. Total abdominal hysterectomy (tah) 1. 2. 3. Gauze Pack Sutures Vicry 1 Plain Nylon 4. Surgical gloves 5. Disposal gloves 6. Betadine/Lotion 7. Nelaton Catheter, spirit 8. Blade, Cotton 9.00 9.00 43.00 0.60 1.80 4.45 3.45 4.50 10.00 2.00 2.00 40.00 185.00

9. Miscellanous 10. Procedure fee (Condition) 11.TAHand Spiral Anaesthesia 12.Maintenance of monitor 13. Electricity 14.Water Total

10.00 200.00 40.00 2.00 1.5 1.00 342.30

e.

Tah with general anaesthesia Total cost of d. General anaesthesia Total 342.30 100.00 442.30

Obstetrics and gyaecology f. 1. 2. Caesarian section Gauze Pack 6.00 6.00

3.

Suture-vicry1 -plain -Nylon 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Total Surgical gloves Disposable gloves Betadine/Lotion Nelatoncatheter, spirit, blade, cotton Miscellaneous Spiral Anaesthesia Extra Anaesthesia Maintenance of monitor Electricity Water

21.50 0.60 0.60 4.45 2.00 4.50 10.00 100.00 40.00 20.00 2.00 1.50 1.00 220.15

g.

Caesarian section under general anaesthesia Total cost off Generala naesthesia Maintenance of monitor 220.15 100.00 2.00

Total cost

322.15

h.

Bilateral tubal ligation 1 2. Gauze Suture-vicry 1 -plain -Nylon 3. 4. 5. 6. 7. 8. Surgical gloves 4pair Disposable gloves 1/2 Betadine/Lotion Nelatonca theter, spirit, blade, cotton Miscellaneous Procedure fee (Condition) 3.00 4.30 0.60 0.60 1.48 1.00 2.00 3.00 5.00 40.00 60.98

Total cost

The above disease and treatment procedures illustrates the itemized billing system in Tema General Hospital.

Data analysis On the question of the system of billing in Tem General Hospital, 75% of the selected sample staff was aware that, the Hospital uses the G-DRGS system. According to them, the Hospital was asked not to use any system of billing apart from G-DRG system for both Insured and Uninsured. It was to serve as an incentive for the uninsured clients/patients to enroll into the National Health Insurance Scheme. Fifteen (15%) of the staff knew that, the hospital uses both the Itemized and the GDRGS system of billing, because in the second quarter of the year 2010, the management decided to introduce the itemized billing system to cater for the uninsured client/patient. The major reason for the introduction of the itemized billing was that, G-DRGS tariffs was inadequate considering the kind of service the Hospital offers. Others was due to the location of the Hospital, there are always foreigners who are not insured seeking health services in the hospital, and therefore, the Hospital should take the opportunity to recover the right cost to enable it procure consumable to give quality health service to patients. Ten (10%) of the staff was not sure of the system in use, and therefore referred researcher to accounts/finance department. The question of which institution developed the itemized billing/tariffs? Only 30% of the staff knew it was developed by the management of the Hospital. 70% thought it was done by Ghana Health Service (GHS) in Consultation with Ministry of Health (MOH) which is then distributed through GHS to all hospital for implementation. The third question of how the itemized billing was determined? Again only 30% which was mostly paramedical staff or supporting staff said, it was determined on the bases of item by item to enable the hospital recover the cost of item/ consumables use for a

patient/client. Majority of the 30% staff was finance staff. 70% could not tell, but with mix feeling that, some of the item cost was not realistic, special oxygen and anaesthetic drugs which are usually part of the procedure or operation in the theatre. Most of the service providers think that, there should be margin of profit, but the management staff is thinking that as public institution where all salaries and wages as well as capital expenditure are undertaken by Government it should only recover cost and not to make profit. On question four, 70% thought the G-DRGS was determined by the Metropolitan Mutual Health Insurance Scheme, simply because the schemes are near to Tema General Hospital. They did not even know that, the schemes were been regulated from the National Health Insurance Authority. They did not also know that GHS was involved in the determination of the G-DRGS tariffs. According to the NHIS manual of 2008 page one (1), it was done in consultation with all stakeholders including GHS. On the question on discussion, 30% management or supporting staff was sure that the tariffs were developed in conjunction with other stakeholders. Question (5) five which sort to established how the G-DRGS tariffs were determine also came out with almost the same result as the previous question, about 75% could not tell how it was determined, even though the use it. They claimed there was no training on the GDRGS tariffs, hence their answer of no knowledge on the determination of tariffs. The 25% who have knowledge about the tariffs expressed mix feelings. The conceptual framework of which the tariff was developed seems not achieving the standards they sort to set. Standards such as: 1. 2. 3. The tariff should encourage efficiency and not pay for inefficiency The Tariff should be simple and easy to administer. The tariff should encourage providers to provide good quality care

4. 5. 6. 7.

The tariff should ensure uniformity in claims. The tariff should ensure equity and fairness. The Tariff should be based on the principal diagnosis for each patient The tariff should reflect the total costs, both direct and indirect, except capital and equipment costs, incurred in patient care to form the basis for reimbursement.

8.

The total costs of services are to be arrived at irrespective of who was to pay and irrespective of ownership of the health facility The 25% group believes that efficiency can only be achieved if the right health

infrastructure is provided. According to them, the grouping of hospitals without regards to the level of specialist does not create room for efficiency. In others words no matter the high level of medical infrastructure and the quality of medical and paramedical personnel, once the institution is classified under District Hospital, she must recover her cost using District Hospital tariffs. They believe that due to the group tariff, Tema General Hospital should have been raised to Regional Hospital B. to enable it at least recover a reasonable proportion of the losses. On question (6) six, 99% of the selected staff knew that, out-patient treatment was an all inclusive one, that is consultation and all investigation (Laboratory, X-ray, Scan, ECG) are all added to consultation. 1% could not tell simply because they were new trainees (staff). It came to light from the accounts department that, due to the combinations or all inclusive nature of the G-DRGS tariffs, there is much difficulty to assess the efficiency of Cost and Revenue centre such as the OPD, LAB, X-RAY, SCAN, and ECG which have a different needs of medical resource. According to them, Itemized billing was easy to assess the efficiency of the above mentioned Centres, the G-DRGS system of billing have shifted the standard parameters of

assessing performance in the health sector, making it difficulty to determine the performance of each department. Question (7) seven 65% think that consultation should be Doctor Service and Documentation, while 45% believes, it should be Doctors service and investigation. Question (8) eight, contrary to the responses on seven above, 95% think that there is clear difference in cost between consultations and investigations, according to them, the cost of reagents are very important factor in the treatment of a patient and therefore should not be mix-up or added to consultations. They claim, cost for reagents increase daily and the frequency of request for investigation by medical practitioners have increase as well as the level of specialty. That is the levels of medical judgment without investigation for treatment of patients have reduced. Every Doctor want to be sure of what she/he is treating and therefore will request more investigation than ever. For them, the assumption that, not every patient require investigation should be discarded, because it will create cost problems for the Hospital if all inclusive treatment continue. Question (9) nine based on the itemized billing, 90% knows that it will cost between GH5-GH10 to conduct an investigation for a simple disease, and 10% do not know because they have no access to itemized tariff. Question (10) ten the same percentage as in question (9) knows that, it will cost between GH60-GH100 to investigate complex disease and those who do not know remain the same as in the previous question. Responses to question (11) eleven also brought to light of 90% with certainty that, it will cost between GH6-GH10 to come out with a clean x-ray in a simple investigation and 10% do not know due to non access of the itemized tariffs. For a complex x-ray for question (12) twelve, the percentages in question eleven remain the same regarding their knowledge which they confirm to be between GH60-GH100.

On question (13) thirteen, according to the response it cost far more than just the production. They claim all the papers use for ECG investigation are all imported at cost of GH10.00 in addition to the special gel used in conducting the investigation. 85% of the staff said, the cost of ECG will be above GH12. 15% of staff could not come out with any figure because they have no knowledge on the determination of the tariffs. Question (14) fourteen 75% of they Medical officers and others involves in performing this investigation is between GH10-GH12. Question (15) 90% of the staff said, it was possible to conducted all investigation in Tema General Hospital. 10% also agreed with the 90% but indicated that, Tema General Hospital can not conduct CTC scan. According to them, this is only done in korlebu Teaching Hospital. Question (16) 100% of the staff think that it is not feasible to combined investigation with consultation. According to them, it will be difficult to access the performance of the Revenue and Expenditure centers. Question (17) seventeen 100% of the respondents stated that it was not possible to differentiate between feeding, investigation, Medical consumables and documentation in an patient billing or charge since under the G-DRGS system, they are included in the tariffs determined by the system. Question (18) eighteen, 100% responded in the negative. Question (19) nineteen, 95% said, it was the combination of medical services, consumables and drugs, whiles 5% could not determine the combination. Question (20) 100%, knew that patients are fed three times a day. Question (21) 25% could estimate the cost of meals, 75% could not tell but refer researcher to the catering department in the hospital. They estimated the cost between GH2-GH5. Question (22), 99% think that the introduction of G-DRGS did not improvement the Revenue base of the Hospital, according to them, it rather introduce loss due to the fact that

several cost and revenue centre are combined making it impossible to assess the performance of those centre. 1% could not respond to the question, because they have little knowledge about the G-DRGS system of tariff. Question (23) 20% said the Hospital was losing between 5%-10% monthly due to either the patients taking filled claim form home or the insurance schemes rejecting the claim for inconsistency in diagnosis and drugs prescribed for patients and many others factors. 80% could not tell the losses, but are very sure that the Hospital lose so much In the G-DRGS system of billing. Question (24) 95% said it take the NHIS from three months and above after submission to get reimbursement. 5% could not put time period but said the NHIS delays in the payment. Question (25) 92% of the staff state the recovery rate between 90%-95% while 12% could not tell but state knowledge of some percentage loss in the reimbursement. Question (26) 99% said, service and drugs were separately bill and therefore separate accounts are been maintained for each.1% thinks the are put together. Question (27) 30% know of the exclusion of capital from the determination of the GDRGS System. 70% thought all was factor in the determination of G-DRGS system. Question (28) 97% said, salaries was paid by (GOG) Government of Ghana, 13% said their salaries are paid from the (IGF) Internal Generated Fund. Question (29) 100% said, it was difficult to assess performance since cost and revenue centers are put together in the G-DRGS system.