December 18, 2020
The proportion of US inpatient admissions assigned to a diagnosis related group (DRG) with a major complication or comorbidity increased for 15 of the 20 highest-reimbursed DRG families between 2012 and 2016—yet researchers found no commensurate increase in comorbidity burden or risk-adjusted mortality, according to results published in JAMA Network Open.
“In addition, DRG shifts were associated with a significant increase in estimated payment over time,” wrote lead author Ty J Gluckman, MD, of the Center for Cardiovascular Analytics, Research, and Data Science at the Providence Heart Institute, Portland, Oregon, and colleagues. “Hospitals had an increase in reimbursement to care for patients who did not appear to be any sicker in terms of overall comorbidities or risk of death but were documented as such.”
The retrospective cohort study used all-payer data from the National Inpatient Sample for admissions assigned to one of the top 20 reimbursed DRG families. DRG families center around patient conditions, such as heart failure, with two or three levels each, depending on patient complexity and whether complications or comorbidities, or major complications or comorbidities, are present, the study explained. Researchers were interested in identifying trends in DRGs with a major complication or comorbidity at US acute care hospitals over the 5-year period.
The study found a significant increase in the proportion of DRGs with a major complication or comorbidity in 15 of 20 DRG families over the study period. However, comorbidity scores and risk-adjusted mortality rates were largely stable. In the case of eight DRG families, risk-adjusted mortality rates improved.
The DRG shifts over the study period were associated with at least $1.2 billion in increased payment, according to the study.
“The $1.2 billion in increased payment is likely an underestimate because our calculations used publicly available Centers for Medicare & Medicaid Services payments applied to an all-payer population,” researchers noted, pointing out payments by commercial payers typically exceed Medicare payments for DRGs.
Gluckman TJ, Spinelli KJ, Wang M, et al. Trends in Diagnosis Related Groups for Inpatient Admissions and Associated Changes in Payment From 2012 to 2016. JAMA Netw Open. 2020;3(12):e2028470. doi:10.1001/jamanetworkopen.2020.28470