1. Jacksonville University School of Nursing Daniel DeBee Colleen Glasco Candice Pawloski September 8, 2015

2. What are DRGs? Method of assigning a numerical value to an acute care patient in hospital setting Associated with a reimbursement structure or “price tag” to simplify Medicare billing process Medicare payment correlated to numerical value rather than length of stay

3. Guidelines for DRGs System Formation Patient characteristics used in the DRG definition should be limited to information routinely collected on the hospital billing form Manageable number of DRGs that encompass all inpatients Contain patients with similar pattern of resource intensity Contain patients who are similar from a clinical perspective (Bielby, 2010)

4. How are DRGs Assigned? Primary diagnosis Secondary diagnosis Principle procedure Additional procedures Age Sex Discharge status (Finkelman, 2012)

5. Other DRG Factors The reimbursement a hospital receives for specific DRGs are affected by: Location (rural/urban) Wage index of area Teaching hospital status House staff training Other recognition outliers (Finkelman, 2012)

6. Examples of DRGs #001 – Heart transplant or implant of heart assist system w/mcc (major complications of comorbidities) #100 – Seizures with MCC #500 – Soft tissue procedures w/ MCC #999 – Increase in ambulatory care (Finkelman, 2012)

7. Effects of DRGs Decreased length of hospital stays Increased need for home health care Increased long-term care facility Increased in ambulatory care ( Finkelman, 2012)

8. Policy Initiatives Conversion of the current ICD-9-CMCode to current version ICD-10-CM Mirrored DRGs for ICD-9 to ICD-10 Take effect October 1, 2015 (Mills, 2015)

9. Difference between ICD-9 and ICD-10 Increased specificity Removal of distinctions no longer in common use (ex. Benign and malignant hypertension) Chronic diseases no longer coded as principle diagnosis but secondary (ex. Anemia) (Mills, 2015)

10. ICD-10 Effects on DRGs Exact replication of DRGs not possible Potential impact on hospital payments Optimization of DRGs not able to be complete until data established from ICD-10 payment weights Will need 2 years of data before optimization can occur (Mills, 2015)

11. Affects on Hospitals Will need to improve documentati0n MOST IMPORTANT Improve coding precision Continue to decrease length of stay while providing quality care (Mills, 2015)

12. DRGs Future Implemented to save Medicare costs for inpatients Due to increasing age and fewer people in workforce, government will need to: Cut costs and/or increase taxes Currently reduced reimbursement due to Hospital acquired conditions Quality initiatives Continue with updates and changes Alterations due to the Affordable Care Act Addition of Outpatient facilities to DRG payments (Mills, 2015)

13. Policy Making Process Input from healthcare professionals is important and have effect on policy outcome Nursing practice affected by health care policy Many nurses delving into unknown world of legislation to: Assist with change Improve policies Improve laws Improve protocols (Finkelman, 2012)

14. Policy Making Process (continued) Nurses provide valuable insight to policy development Involvement and teamwork are necessary for successful policy development For nurses to be successful, it is important to have: “the power, the will, the time, and the energy, along with the political skills needed to ‘play the game’ in the legislative arena” (Abood, 2007)

15. How to get involved Join working committees or groups Writing letters to local newspapers or federal representatives, politicians, congressmen Joining professional nursing organizati0ns Involve coworkers

16. Nursing Organizations National Council of State Boards of Nursing(NCSBN) Create NCLEX exam Build and maintain relation ships with educationalists, government officials and policy makers Ability for boards of nursing to act and counsel together on matters of interest Many state and specialty organizations sponsor: Annual legislative days Fellowships Policy Workshops (Abood, as cited in Hofler, 2006)

17. Nursing Organizations (continued) Provide easy access to experienced nurses wiling to become mentors Monitor public policy Offer education for members to learn about healthcare policy Resource for reliable information related to policy issues and policy makers

18. Advantages to Getting Involved Enhance individual advocacy efforts Access to more resources Able to strategize more effectively Increase awareness to pros and cons of policy Influencing other team members

19. References Abood,S. (January 31, 2007). “Influencing Healthcare in the Legislative Arena”. OJIN: The Online Journal of Nursing. Vol. 12 No. 1, Manuscript 2 Bielby, J. (2010, April 1). Evolution of DRGs (Updated). Retrieved September 7, 2015 Bushell, B. (2013). The Evolution of DRGs. AAOS Now. Retrieved from: http://www.aaos.org/news/aaosnow/dec13/advocacy2.asp http://www.aaos.org/news/aaosnow/dec13/advocacy2.asp Finkelman, J. (2012). Leadership and management for nurses: Core competencies for quality care (2 nd ed.). Boston: Pearson. Mills, R., Butler, R., Averill, R., McCullough, E., Fuller, R., & Bao, M. (2015). The Impact of the Transition to ICD- 10 on Medicare Inpatient Hospital Payments. Journal of HIMA. Retrieved from: https://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html Quentin, W., Scheller-Kreinsen, D., Blümel, M., Geissler, A., & Busse, R. (2013). Hospital payment based on diagnosis-related groups differs in europe and holds lessons for the united states. Health Affairs, 32(4), 713-23. Retrieved from: http://ezproxy.ju.edu:2048/login?url=http://search.proquest.com/docview/1337185251?accountid=28468 http://ezproxy.ju.edu:2048/login?url=http://search.proquest.com/docview/1337185251?accountid=28468