1. www.drg.ro1 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. www.drg.ro2 ROMANIA: 22,500,000 inhabitants 42 counties Capital – Bucharest, 2,500,000 inhabitants Social Health Insurance System (1997) 4.2% of GDP for health (2002) – 70 USD per capita Main health system actors: Ministry of Health and Family – policy National Health Insurance House – financing College of Physicians – quality of care Providers – primary care, ambulatory, HOSPITALS, others

3. www.drg.ro3 Problems/Solutions 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)

4. www.drg.ro4 Practical Solution: Case Based Financing System 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

5. www.drg.ro5 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. www.drg.ro6 DRG National Project 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)

7. www.drg.ro7 2001, 23 Project Hospitals 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

8. www.drg.ro8 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. www.drg.ro9 2002, Implementation 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

10. www.drg.ro10 CMI and ALOS January 1, 2001 – July 31, 2002 CMIdays year/month

11. www.drg.ro11 Top 10 Romanian DRGs compared with Hungarian data 0,0% 0,5% 1,0% 1,5% 2,0% 2,5% 3,0% Hipertensiunea arterială Naşterea vaginală fără dg complicat Otită medie şi inf resp.sup. vârsta 0-17 ani Nou-născutul normal Probleme medicale ale spatelui Insuficienţa cardiacă şi şocul Avortul cu dilatare şi chiuretaj, chiuretaj prin aspir. sau hist. Boli ale fic cu exc tumorilor, cirozei, hepatitei alcool fără CC Alte interv chirurg asupra sist. musc-scheletal si a tes conj fara CC % cases Hungary % cases Romania

12. www.drg.ro12 ALOS for Romanian top 10 DRGs compared with Hungarian data 0 2 4 6 8 10 12 14 Hipertensiunea arteriala Nasterea vaginala fara dg complicat Otita medie si inf resp. sup. varsta 0-17 ani Nou-nascutul normal Probleme medicale ale spatelui Insuficienta cardiaca si socul Avortul cu dilatare si chiuretaj, chiuretaj prin aspiratie sau histerectomie Boli ale ficatului cu exc tumorilor, cirozei, hepatitei alcool fara CC Alte interv chirurg asupra sist. musc-scheletal si a tes conj fara CC ALoS Hungary ALoS Romania

13. www.drg.ro13 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. www.drg.ro14 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. www.drg.ro15 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. www.drg.ro16 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. www.drg.ro17 THANK YOU FOR YOUR ATTENTION, GREETINGS FROM ROMANIA!