The CMS diagnostic related groups (DRGs) have undergone numerous refinements since first introduced in the early 1980s, but they remain essentially a tool to support the CMS prospective payment system. What would a grouper that focused on clinical categories rather than payment look like? For the answer, take a tour of our new product – Guideline Analytics.
Guideline Analytics uses standard claims data elements — diagnosis/procedure codes and patient demographics, for example — to assign each inpatient admission to an Optimal Recovery Guideline (ORG) or General Recovery Guideline (GRG) category drawn directly from our acute care content —Inpatient & Surgical Care and General Recovery Care. Each admission is categorized by a principal ORG or GRG code, subsidiary ORG codes, and a severity category based on the comorbidity methodology developed by CMS for its DRG system, complication/comorbidity (CC) and major CC.
The results are easy-to-manipulate data warehouse analytics and/or an Excel spreadsheet report that allows you to analyze performance against optimal outcomes, compare yourself to peer organizations, and identify clinical areas where you can provide care more effectively.
Why not simply use the MS-DRGs to accomplish this analysis? The short answer is that the MS-DRGs were built for a different purpose. For the long answer, let’s say you’re the medical director at a medium-sized health plan. (The data that follows is actual 2010 data from such an organization.) You’re trying to understand how your network is addressing obesity using surgical procedures. Specifically, you want to know how many surgeries are being performed on an inpatient basis that – under optimal conditions – could be performed on an outpatient basis. The DRGs provide three categories for Operating Room Procedures for Obesity. However, two of those categories are for cases with significant complications and comorbidities– unlikely candidates for outpatient surgery, and in practice, only about one-sixth of cases. That leaves one large category (DRG 621) for analysis. Not much granularity.
Guideline Analytics breaks DRG 621 into seven MCG™ guideline categories (see chart below), including S-515 – Gastric Restrictive Procedure without Gastric Bypass by Laparoscopy. Why is S-515 so interesting? According to current medical literature, given optimal conditions, patients can receive this procedure on an outpatient basis. Yet 28% of such procedures are being performed on an inpatient basis at an overall cost of $1.3 million. Is that a reasonable percentage? Should you dig deeper into the data? Guideline Analytics provides risk-adjusted benchmarks – covering different lines of business, different regions of the country, different degrees of medical management, and different delivery systems – so you can assess where that 28% places you compared to peer organizations. Guideline Analytics are linked to MCG™ guideline categories in terms of their foundation only, the Guideline Analytics are not dependent on a client having a license to MCG™ products. Due to the linkage of the Guideline Analytic categories to MCG™ we know that the recent medical evidence on this procedure, S-515, includes five published studies showing the safety of outpatient treatment and four articles describing situations in which inpatient care may be required. This unique combination of statistical data and medical evidence from peer-reviewed sources allows you to decide your next step with confidence.
2010 Inpatient Medical Claims Analysis for Medium-Sized US Health Plan