Introducing Diagnosis-Related Groups in countries with smaller populations - Path towards implementation and typical challenges
Natascha Andres a, Philipp Wacker a
Introduction
Reforming health systems is a top priority for countries worldwide, which is emphasized by the UN sustainability goal of ensuring access to quality health care for people in all countries. However, experience tells us that triggers and challenges are drivers. For example, while some countries struggle with serving a fast-growing population, other countries' challenge is preserving current service levels considering ageing societies and workforce shortages. Patient classification systems (PCS) provide important information to make thoughtful decisions addressing those challenges. Thus, PCSs and their corresponding use in health economics or reimbursement systems are almost always main components of reform initiatives.
Health system reforms - especially in countries with smaller populations - face distinct challenges in contrast to larger populated countries. Those challenges are associated with a lack of resources, knowhow, and limited opportunities to leverage economies of scale through reforms. Thus, a typical question in countries with smaller populations is whether existing classification systems can be leveraged or whether independent systems are required to achieve the reform goals.
We will present a consolidated summary of the experiences made while working with governments in different countries to design and implement PCS systems as a foundation for DRG reimbursement system reforms.
Methods
Our report outlines lessons learned, challenges faced, and success factors derived from our field work in the above-mentioned context. We focus on practical experience with relevance for the audience. This includes highlighting open research questions related to the implementation of PCSs for clinical representatives and other scholars as well as practical guidance to decision-makers implementing respective reforms.
Results
Our experience revealed critical success factors for the implementation of PCS for DRG reimbursement systems. Those include elaborating:- robust guiding principles based on reform goals,
- a clear view on the current baseline of classification and payment archetypes,
- a clear process for evaluating available classification systems and making necessary adaptions
- a clear view on required resources and sensible timeframes for the reform, and
- a plan for the stakeholder preparation.
However, crucial to successfully execute PCS and reimbursement reforms is the establishment of a strong governance system, which institutionalizes the reform programme. This requires the right decision-makers at appropriate levels within the programme.
Conclusions
PCS and reimbursement reforms are key enablers in health system transformation. However, countries with smaller populations face limitations in available resources and knowhow to self-develop or customize a classification system. Reforms in patient classification and reimbursement systems are not a magic bullet in answering to the above-mentioned challenges and one size does not fit all. The success of the reform is dependent on the design and implementation approach as well the capacity of the entire health system and its responsible authorities. Especially the application of existing classification systems can lead to overoptimistic implementation plans, which prevent necessary adjustments of the PCS to the country context. Awareness of key success factors helps avoiding expensive and time-consuming obstacles during the reform implementation.
a KPMG, Germany
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