HRGs and standard tariffs in rehabilitation

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HRGs and standard tariffs in rehabilitation

• Prof Lynne Turner-Stokes
• RRU, Northwick Park Hospital
• Academic Rehabilitation
• Kings College London

2
Payment by Results (PbR)

• Instead of block NHS contracts,
• Annual trust income negotiated in advance
• Activity rates notional, if specified at all
• Under PbR Cost / volume contracts
• Payment per case treated
• Standard national tariff
• Categorisation of case type and costs
• Nationally agreed case-mix classification
• Payment by Activity not Results

3
Critical elements

• Coding
• Healthcare Resource Groups (HRGs)
• Standard groupings of clinically similar
  treatments
• Units of currency
• form basis for standard tariffs
• Still under development (current version v4)
• HRGs codes and costs informed by
• Diagnostic codes e.g. ICD-10
• Procedure codes e.g. OPCS

4
Costs

• Reference costs
• Cost of providing each HRG in each trust
• National tariff
• National price to be paid for each HRG
• weighted average of trust reference costs
• Weighting Adjustments
• Market Forces Factor (MFF)
• Multiplier unavoidable cost variations
• Geography, staff pay etc

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National tariff

• Includes all costs
• Of providing treatment spell
• Clinical - Diagnostic, intervention, care
• Non clinical - Cleaning, maintenance, food
• Specialist services
• Receive additional weighting
• (Some specified high cost low volume services
  excluded)

6
Flow of data

• Hospital Episode Statistics (HES)
• Pt record level data
• All in NHS hospital admissions England
• Annual snapshot of a subset of the data
• To the NHS-wide clearing service (NWCS)
• Subset - Approx 11 million admitted pts
• NWCS - Replaced by SUS (secondary users service)
• Provides pseudonymised data
• For management and clinical purposes (including
  PbR)
• Gathered from commissioned datasets (CDS)
• Complete data

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Where are we to date?
8
NHS dys-interconnectivity

• NHS Information Authority (NHSIA)
• Closed 2005 split in to two departments
• Connecting for Health
• Responsible for ICD-10 and OPCS codes
• NHS Information Centre
• Responsible for HRGs and Datasets
• Data not fully inter-connectable
• Mutual co-operation patchy!
• Compounded by disparate coding systems.

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Coding 3 systems

• Hospitals ICD-10 codes (international)
• Diagnostic codes - problematic if no diagnosis
• GPs Read codes (UK)
• Clinical terms accepts symptoms
• (In future combined under Snomed-CT)
• International Snomed-RT (reference terminology)
• Combined with Read and mapped to ICD-9 (!)
• Over 366K concepts
• symptoms, signs, pathology, risk factors, objects
  
• Under development - due to go live 2015

10
PbR slower than planned

• Expected that by 2005/6
• 80 of NHS activity included
• 2003/4
• National tariffs applied to 15 HRGs
• Cost volume SLAs for 6 specialities
• Including urology
• PbR currently covers
• 20 in-pt spells
• 50 outpatient activity

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Problems

• Variation in costs - Higher than expected
• Technical reasons
• Incomplete information
• Variations in coding practice, costing
• Actual clinical differences
• Level of services offered
• Expensive investigations, drugs, interventions
• Complexity of population served
• Specialisation - Selected group of complex pts

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Casemix classification

• USA 20 years of casemix classification
• Diagnostic-Related Groups (DRGs)
• Trialled in England 1982/3
• Analysis of 14 million hospital episodes
• DRGs did not fit casemix of NHS
• Other countries developed their own systems
• Australia (AR-DRG), Canada (CMG) etc
• UK equivalent classification
• Healthcare Resource Groups (HRGs)

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Example HRGs - stroke
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Wide variation in complexity
Complexity of need
High cost / low volume
Av. cost
Low cost / high volume
Pts needing rehabilitation
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Different levels of service
Complexity of need
Complex Specialised Rehabilitation (CSR) -
Tertiary services
District Specialist Rehabilitation (DSR)
Av. cost
Local General Rehabilitation (LGR)
Pts needing rehabilitation
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Different levels of complexity
Complexity of need
Complex Specialised Rehabilitation (CSR) -
Tertiary services
District Specialist Rehabilitation (DSR)
Areas covered by proposed HRGS
Av. cost
Local General Rehabilitation (LGR)
Pts needing rehabilitation
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Banding for different levels of complexity in
rehabilitation
Complexity of need
Complex Specialised Rehabilitation (CSR)
District Specialist Rehabilitation (DSR)
Cost bands
Areas covered by proposed HRGS
Local General Rehabilitation (LGR)
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Banding for different levels of complexity in
rehabilitation
Complexity of need
Complex Specialised Rehabilitation (CSR)
District Specialist Rehabilitation (DSR)
Cost bands
Areas covered by proposed HRGS
Local General Rehabilitation (LGR)
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Experience in other countries

• Diagnosis-related groups
• In rehabilitation
• Diagnosis poor determinator of cost
• Function-related groups
• USA
• FIM-FRGs
• Australia
• FIM / Barthel

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Australian Models

• Two case-mix systems
• VicRehab
• CRAFT classification
• Based on Barthel Index
• High and Low scores ( cut-off BI 60/100)
• Weighted episode rates
• Level II services only (stroke orthopaedic,
  neuro)
• Level I designated services, block contract.
  (HI, SCI)
• AROC (Australasian Rehabilitation Outcomes
  Centre)
• AN-SNAP-II classification
• Based on FIM scores (motor and cognitive) - 6
  levels
• Blended payment model

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Both Australian systems

• Per diem rates
• Designated rehabilitation units
• Weighted payments
• based on complexity of need
• Physical dependency
• Surrogate measure of complexity

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Function-related models

• Work reasonable well
• Early post acute rehab
• Emphasis on physical disability
• Rapidly changing
• Fixed episode payment systems
• Poorer functional outcomes
• Work less well
• Brain injury
• Walking wounded cognitive-behavioural factors
• Low awareness states
• On-going disability management
• Neuro-palliative rehabilitation
• Progressive neurological conditions

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Neuro-rehabilitation in the UK

• Mixture of approaches
• Single incident rehab
• Neuro-palliative rehabilitation
• In-pt and community services
• State commitment to long-term care
• Cost-efficiency of rehabilitation
• In reducing the cost of long term care

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Northwick Park Hospital

• Regional Rehabilitation Unit
• Catchment population 5 million
• Tertiary specialist service
• Younger adults
• Complex rehabilitation needs
• Beyond scope of local services
• Mean age 43 (SD 14) years
• Average LOS 3 - 4 months
• Up to 6 months
• Occasionally 1 year or more.

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Banding for dependency

• Northwick Park Dependency Scale (NPDS)
• Ordinal measure of nursing dependency
• High NPDS gt25 - Two people for most tasks
• Medium NPDS10-25 - One person for most tasks
• Low lt10 - Largely independent
• NP Care Needs Assessment (NPCNA)
• Computerised algorithm
• Generic assessment of care needs in the community
• Time table of care needs discharge planning
  tool
• Estimated care hours
• Approximate weekly cost of care

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Highly dependent patients
6-week admission for rehabilitation
Care package Admission 2 people three times a
day (500/wk) Discharge FIM / Barthel Index
unchanged 1 person three times a day (250/wk)
Cost of rehab 18,000 Cost offset in 18 months
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5 year Cohort data 297 consecutive admissions
Turner Stokes et al JNNP 2006 77 634-639
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Diminishing returns
Cost of care
Months
0 1 2 3 4 5 6
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Diminishing returns
Cost of care
Months
0 1 2 3 4 5 6
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Cost-efficiency of long stay pts

• Long stay pts
• NPDSgt25
• Staygt125 days
• n51
• Mean cost 52K (LOS 6 months)
• Savings in care 950/week
• Offset 14 months

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Most complex cases

• Case-by-case funding
• Continuous dialogue with funders
• Relies on good serial data
• Require validated assessments for
• Input - level of intervention
• To provide accurate costing
• Outcome
• Meaningful change
• Value for money

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Factors determining costs in rehab
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Input (costing) measures

• NP nursing Dependency Scale (NPDS)
• Basic care and special nursing
• NP Therapy Dependency Assessment (NPTDA)
• Therapy interventions
• No of Disciplines, Therapy time
• Special equipment / facilities
• Medical interventions

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Factors determining costs in rehab
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Time consuming

• NPDS
• 3-5 mins to score
• Familiar nurse or carer
• NPTDA
• 5-10 mins
• MD Team
• Can we simplify this?

37
Simple banding measure

• Rehabilitation Complexity scale
• 15 point measure
• C Basic care needs (0-3)
• N Special nursing needs (0-3)
• T Therapy hours (0-6)
• M Medical environment (0-3)
• E.g. RCS 7 (C2 N1 T3 M1)

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Basic care and support needs
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Skilled nursing needs
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Therapy Intervention
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Medical management
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RCS useful for banding?
Complexity of need
Complex Specialised Rehabilitation (CSR)
District Specialist Rehabilitation (DSR)
Cost bands
Areas covered by proposed HRGS
Local General Rehabilitation (LGR)
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UK national survey

• 45 units
• 20 complex specialised services
• 25 district specialist services
• Cross sectional survey
• 1 week
• RCS scores for all pts on unit
• 5-47 pts scored
• Total 677 scores

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Outcomes

• Value for money
• Functional Independence
• Barthel Index, FIM FAM
• On going cost of care
• NPDS / NPCNA
• Person centred outcomes
• Goal attainment scaling (GAS)

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Banding for different levels of complexity in
rehabilitation
Complexity of need
Inputs
Outcome
FIM FAM
Banding NPDS NPTDA
Complex Specialised Rehabilitation (CSR)
BI GAS
Banding RCS
District Specialist Rehabilitation (DSR)
Areas covered by proposed HRGS
Local General Rehabilitation (LGR)
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Conclusion

• Longer rehab programmes
• Can be cost-efficient for some patients
• Careful selection and monitoring
• Evaluation of outcomes and cost-efficiency
• Need granularity
• Banding to meet the cost of complex cases
• Weighted payment systems
• Now starting to pilot the systems