Academic journal article Australian Health Review

Mature Use of Casemix - Are We There Yet?

Academic journal article Australian Health Review

Mature Use of Casemix - Are We There Yet?

Article excerpt


In this paper we consider the progress made in using casemix in Australia. We argue that while the casemix infrastructure has been highly developed and the casemix-based funding systems of some states are mature, there is still more development needed to use the data for clinical questions such as quality improvement activities. Further research is needed to establish what is needed to describe the impact of casemix on clinicians and hospitals in a context of increasing accountability and transparency and where questions of efficiency cannot be ignored.

Aust Health Rev 2007: 31 Suppl 1: S59-S67

IT IS WIDELY ACCEPTED now that casemix is a tool and a means to an end rather than an end in itself.1 The implementation of casemix in Australia can be traced back to the demonstration projects in the mid 1980s, and over a decade has passed since the earliest implementations of casemix-based funding in Victoria and South Australia. It is timely then to consider the progress we have made and to ask whether we are using the casemix tool in the best way.

The body of this paper is divided into four areas of discussion: technological issues concerned mainly with grouper development and performance; casemix-based funding systems; the diffusion of casemix information into clinical issues especially concerning quality of care and patient safety; and the organisational impact of casemix especially through clinical directorates.

For the purposes of this paper, the mature use of casemix is defined as using casemix information to its full potential. This will necessarily mean different things for each of the four areas. The Box shows the characteristics that indicate a mature use of casemix for each of the four areas under discussion.

Casemix infrastructure - coding, groupers, and information systems

Australia has become a world leader in the design and production of casemix groupers and the underlying clinical classification system. The evidence for this assertion is the use over the last decade or more of the Australian National or Refined Diagnosis Related Groups (ARDRGs) as the starting system for several countries including Singapore and Germany. Most recently, ARDRGs have been implemented in casemix initiatives in Turkey2 and Ireland.3 The ICD-IO-AM classification system has been a great success, and its acceptance internationally has underpinned the use of the ARDRGs, although some countries such as Singapore used the older versions of grouper that were based on ICD-9-CM. International interest in ICD-10-AM may be due, at least in part, to the fact that ICD-10-CM is not implemented yet in the United States, and so ICD-10-AM is filling that vacuum.

Several authors have compared the performance of the ARDRGs with other groupers.4,5 In summary, these comparisons tend to show that the ARDRGs perform at least as well, or better, than others, although factors such as the quality of the data used for the test have some impact on the results.6

Spectacular progress was made by the Commonwealth Department of Health and Aged Care* in the 1990s under the banner of the casemix Development Program (CDP) in implementing a national casemix infrastructure. Since those heady days, the CDP was superseded by the Hospital Information, Performance Information Program (HIPlP) in 2003, and the scope of the program has narrowed to managing national data collections and the process of updating the DRG classification system. The updating process for ARDRGs run by the Department of Health and Ageing and the National Centre for Classification in Health has been regular, consultative and well planned. However, work is still continuing to introduce and refine emergency, non-acute, subdacute and community patient classification systems. The size of the national database is impressive (it currently contains about 39 million deidentified records) and consists of a mix of demographic, administrative and clinical (diagnoses and procedures) data. …

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