Assessing the performance of a method for case-mix adjustment in the Korean Diagnosis-Related Groups (KDRG) system and its policy implications

• Published in: Health research policy and systems Vol. 19; no. 1; pp. 1 - 98
• Main Authors: Kim, Sujeong, Choi, Byoongyong, Lee, Kyunghee, Lee, Sangmin, Kim, Sukil
• Format: Journal Article
• Language: English
• Published: London BioMed Central Ltd 29.06.2021; BioMed Central; BMC
• Subjects: Accuracy; Asian cultural groups; Classification; Complexity; Consumption; Consumption (Economics); Diagnosis; Diagnosis related groups; DRGs; Health insurance; Hospitals; Inpatient case mix; Methods; Patients; Payment systems; Payments; Performance evaluation; Pilot projects; Prospective payment system; Prospective payment systems; Prospective payment systems (Medical care); Rationality; Resource consumption; Risk adjustment; Validity; Variance analysis; South Korea; United States > US
• ISSN: 1478-4505; 1478-4505
• DOI: 10.1186/s12961-021-00739-5

To evaluate the performance of the patient clinical complexity level (PCCL) mechanism, which is the patient-level complexity adjustment factor within the Korean Diagnosis-Related Groups (KDRG) patient classification system, in explaining the variation in resource consumption within age adjacent diagnosis-related groups (AADRGs). We used the inpatient claims data from a public hospital in Korea from 1 January 2017 to 30 June 2019, with 18 846 claims and 138 AADRGs. The differences in the total average payment between the four PCCL levels for each AADRG was tested using ANOVA and Duncan's post hoc test. The three patterns of differences with R-squared were as follows: the PCCL reflected the complexity well (valid); the average payment for PCCL 2, 3, and 4 was greater than PCCL 0 (partially valid); the PCCL did not reflect the complexity (not valid). There were 9 (6.52%), 26 (18.84%), and 103 (74.64%) ADRGs included in the valid, partially valid, and not valid categories, respectively. The average R-squared values were 32.18, 40.81, and 35.41%, respectively, with an average R-squared for all patterns of 36.21%. Adjustment using the PCCL in the KDRG classification system exhibited low performance in explaining the variation in resource consumption within AADRGs. As the KDRG classification system is used for reimbursement under the new DRG-based prospective payment system (PPS) pilot project, with plans for expansion, there should be an overall review of the validity of the complexity and rationality of using the KDRG classification system.