Casemix - how your ED is paid
The Department of Health has implemented ‘Payment by Results’ (PbR) – a system to link healthcare activity in the NHS with remuneration.
To do this, DH groups patients with similar costs together using Healthcare Resource Groups (HRGs), and the cash is the ‘tariff’ linked to that particular HRG.
In October 2012 The King's Fund published a report based on a review of the English NHS experience of Payment by Results (PbR) and international experience of similar, activity-based payment systems. The report identifies five general lessons about payment systems, draws some conclusions about whether the current Payment by Results system is fit for purpose in view of current and future
challenges and presents options for how reforms to PbR could be taken forward.
HRGs in non-urgent care
HRGs fairly easy to implement in non-urgent care, where there is a well-defined starting point (for example, hernia), a defined intervention (hernia repair), and outcome (no hernia). There is a fairly homogenous patient group with a predictable progression, and therefore costing is relatively straightforward. Note that:
a) the original diagnosis and the outcome are accurately defined by the procedure.
b) the worth of the procedure to the patient can be estimated and the reward tailored accurately to favour procedures that offer good benefits to the patient and society (e.g. hernia repair) at the expense of those that may not (e.g. tonsillectomy).
HRGs in emergency care
HRGs in the acute sector are much more difficult to implement accurately. As described above, HRGs and therefore payment are related to diagnostic testing and treatment activity not complexity or difficulty: doing a difficult spinal fusion operation makes a lot of money for the hospital but unravelling a complex diagnostic problem does not. Note that:
a) both the outcomes and any reward are completely independent of any benefit to the patient or the wider society.
b) the investigations and treatments do not accurately define either the starting condition or the final diagnosis.
HRGs currently use investigations and treatment as surrogate markers for diagnostic complexity because this data is easy to capture.
Unlike the non-urgent sector, the investigation or treatment is only loosely associated with the complexity – a complex wound in a paediatric patient that requires skilled sedation and many sutures results in the same payment to the hospital as a drunk who requires a couple of staples in a minor head wound. A complex psychiatric assessment results in the same payment as reassuring a patient with a cold.
Unlike in non-urgent care, an Emergency Department does not have the option of opting out of treating patients with conditions that are complex or poorly remunerated.
The focus on collecting data for targets and remuneration has caused all other data relating to an Emergency Department attendance (e.g. patient diagnosis, injury surveillance, drug and alcohol, toxicology etc.) to be neglected - see above. This is not in our patients’ interests or the specialty’s interest.
HRGs in the Emergency Department
In April 2011 Emergency Medicine moved to a new HRG system (version 4) that should match remuneration with activity more accurately than the previous version (3.2).
This should be good news for Emergency Medicine, but there are already reports that the PCTs have not passed the increased remuneration on to the Emergency Departments. The PCTs have been funded by DH to pay the increased tariff to the Emergency Departments so there is no reason for them to withhold this money.
Payment by Results arrangements for 2013-14
Confirmation of the arrangements for Payment by Results (PbR) in 2013-14 is now available on the DH website at: http://www.dh.gov.uk/health/2013/02/2013-14-pbr/
Payment by Results 2012/13
The final 2012-13 Payments by Results package has been published by the Department of Health in England. This comes into effect from 1st April 2012.
There are five Emergency care tariffs for services delivered in EDs and minor injury units (MIUs), spread over 11 HRG classifications based on investigation and treatment.
Over successive years the CEM has argued that the sickest patients are not accurately remunerated, and our reasoned argument has borne fruit – the tariffs for the highest acuity patients have increased markedly:
In addition, best practice tariffs have been introduced for a number of emergency clinical scenarios. The aim is to promote management of these conditions on a same day basis [NB must not cross midnight].
The clinical conditions are:
(a) cellulitis
(b) pulmonary embolism
(c) asthma
(d) acute headache
(e) chest pain
(f) lower respiratory tract infections without chronic obstructive pulmonary disease
(g) appendicular fractures not requiring immediate fixation
(h) renal/ureteric stones
(i) falls including syncope and collapse
(j) epileptic seizure (any)
(k) deliberate self harm
(l) deep vein thrombosis (DVT)
The College would like to thank Taj Hassan, the CEM Informatics group and other individuals who have worked very hard with the DH to establish the new best practice tariffs which is a significant step in getting better remuneration for the work Emergency Departments are doing.
You can download the full details of the PbR arrangements from the DH website: http://www.dh.gov.uk/health/2012/02/confirmation-pbr-arrangements/
What do I need to do?
Learn how the funding works so that you can make sure your Emergency Department is paid the full amount due.
Measure the increase in funding due from the move to HRGv4 and report back to Phil McMillan at the CEM (philip.mcmillan@collemergencymed.ac.uk)