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

1. Case Mix in Romania: From Project(s) to National Scale Implementation Dana Burduja, JSI Romanian DRG Project Coordinator dburduja@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 actors:Ministry of Health and Family – policyNational Health Insurance House – financingCollege of Physicians – quality of careProviders – primary care, ambulatory, HOSPITALS, others

3. 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) Problems/Solutions

4. 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 Practical Solution: Case Based Financing System

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

6. 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) DRG National Project

7. 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 2001, 23 Project Hospitals

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. 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 2002, Implementation

10. 0,8 9 8 0,7 7 0,6 6 0,5 5 0,4 4 0,3 3 0,2 2 0,1 1 0 0 2001 08 2001 09 2001 10 2001 11 2001 12 2002 01 2002 02 2002 05 2002 06 2002 07 2001 07 2001 01 2001 02 2001 03 2001 04 2001 05 2001 06 2002 03 2002 04 CMI ALoS CMI and ALOS January 1, 2001 – July 31, 2002 CMI days year/month

11. 3,0% % cases Hungary 2,5% % cases Romania 2,0% 1,5% 1,0% 0,5% 0,0% Nou-născutul normal Hipertensiunea arterială complicat Naşterea vaginală fără dg Insuficienţa cardiacă şi şocul chiuretaj prin aspir. sau hist. Avortul cu dilatare şi chiuretaj, Boli ale fic cu exc tumorilor, cirozei, hepatitei alcool fără CC Probleme medicale ale spatelui CC Alte interv chirurg asupra sist. musc-scheletal si a tes conj fara 0-17 ani Otită medie şi inf resp.sup. vârsta 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 chiuretaj prin aspiratie sau Avortul cu dilatare si chiuretaj, CC Probleme medicale ale spatelui Alte interv chirurg asupra sist. musc-scheletal si a tes conj fara cirozei, hepatitei alcool fara CC Boli ale ficatului cu exc tumorilor, 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

16. 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.

17. THANK YOU FOR YOUR ATTENTION, GREETINGS FROM ROMANIA!