Saizan, Sarah
(2021)
The performance of the MalaysianDRG Casemix
System and financial implications of inaccurate
documentation and coding error.
Masters thesis, Universiti Sains Malaysia.
Abstract
Introduction: The Ministry of Health (MOH) implemented the MalaysianDRG
casemix system in 2010, yet its achievement has not been studied. To date, there
have been no other study on the performance of the MalaysianDRG casemix
system in MOH hospitals. Therefore, its performance cannot be determined and
benchmarked against other casemix system elsewhere, thus hindering future
improvement initiatives.
Objectives: There were three study objectives; 1) to describe the trend of the
MalaysianDRG casemix performance in MOH hospitals from 2017-2018, 2) to
explore factors contributing to poor casemix performance in a MOH hospital
and, 3) to determine the financial implications due to inaccurate documentation
and coding error
Methodology: This study consisted of two parts. Part 1 utilized a sequential
explanatory mixed method design to answer the first and second study
objectives. It began with a cross-sectional study using secondary data to
describe the trend of casemix performance according to national target
indicators in five MOH hospitals in Malaysia. Multistage sampling was applied
in selecting five hospitals representing five regions in Malaysia. All casemix
audit reports between 2017 to 2018 in each hospital were analysed descriptively.
The performance of the four national target indicators were presented for each
hospital. To further understand the factors of poor casemix performance, a case
study was conducted at the hospital with the lowest casemix performance. Data
collection was carried out using in-depth-interviews, observation, and document
reviews, and were analysed using thematic analysis. Part 2 of the study involved
a cross-sectional study using secondary data of 226 audit and re-audit forms oftwo MOH hospitals which underwent re-audit by the Casemix Unit, MOH in
2017. The data collection involved obtaining old and new codes from the reaudit
forms to be entered in the MalaysianDRG casemix costing module to
produce a specific Diagnosis Related Group (DRG) and Cost Group Weight
(CGW). The CGW was multiplied by the latest National Base Rate 2016 to
derive the price per case (PPC) for each DRG. A descriptive cost analysis was
conducted to measure financial implications before and after the re-coding
process in the re-audits. The statistical differences in PPC were measured using
paired sample t-test.
Results: All five hospitals achieved the targets for the third and fourth indicators
pertaining to coding accuracy in main and other condition. However, four
hospitals achieved below the intended targets for the accuracy in documentation
of main condition, and completeness in documentation of other condition.
Thematic analysis of the case study discovered four themes with 14 subthemes
detailing the factors contributing to poor casemix performance at Hospital E.
The themes were poor organizational commitment, resource management
issues, information system failure, and poor stewardships in leading casemix
initiatives. The final part of the study revealed the difference in costs of
RM227,657 due to inaccurate clinical documentation and RM 68,216 for coding
error. The differences between mean (SD) cost per case of the original vs. new
codes due to inaccurate clinical documentation [RM10,208.19(12273) vs.
RM11,244.53(13785.27), p<0.05], and coding error [RM10,208.19(12273.04)
vs. RM11,215.52(13798.03) p<0.05] were statistically significant.
Conclusion: It can be concluded that even though the performance of the
MalaysianDRG casemix system in MOH hospitals is moderate, the trend of the
national target achievements is showing positive signs of improvement. The
MalaysianDRG casemix system is the way forward in hospital management and
if utilized optimally, may yield great financial benefits to MOH. However,
before this can be achieved, factors that hamper its success and flaws that result
in costly financial implications must be overcome. The study findings may be
used to spread awareness and formulate targeted solutions towards future
excellence in the MalaysianDRG casemix system.
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