Assessing a financial incentive for reducing length of stay of psychiatric inpatients: Implications for financing psychiatric services
QUESTIONS UNDER STUDY: Restricted government budgets are forcing countries to implement more efficient health measures. Unlike in somatic medicine, the process of evaluating payment systems in psychiatry in Switzerland is ongoing. A pilot approach in one psychiatric hospital, here called “new remuneration system (NRS)”, was introduced to better control length of stay (LOS) by combining a lump sum with degressive daily rates. This is a first evaluation of the NRS in terms of a reduction of the LOS, and the prevention of early readmissions by analysing meaningful outcome categories.
METHODS: The total sample consisted of N = 66,626 psychiatric inpatient episodes and a subsample of N = 60,847. Data were collected from the hospital using the NRS and three comparison hospitals in the Canton of Zurich. The observation period covered 2005 to 2011, the years before and after the implementation of the NRS in 2009. To examine the outcome categories, general logistic models were used.
RESULTS: The median LOS at all four hospitals was 21 days (IQR: 46–8). In the NRS-hospital, there was a significantly higher proportion of 6 to10-day stays after 2009, indicating an influence of the lumpsum measure. At the same time, data revealed a somewhat lower proportion of readmissions within 30 days in the NRS-hospital. In general, effect sizes were small.
CONCLUSIONS: Within the observation period of three years since 2009, the NRS had a small influence on LOS and early readmissions. The stability of effects needs to be monitored. More sophisticated modellings of the NRS might lead to further insights.
- OECD. Health at a Glance 2013: OECD Indicators [Internet]. Paris: The Organisation for Economic Co-operation and Development (OECD); 2013 [cited 2013 Dec 12]. Available from: http://dx.doi.org/10.1787/health_glance-2013–en.
- WHO. Mental health policy and practice across Europe [Internet]. Kopenhagen: World Health Organization; 2007 [cited 2013 Dec 12]. Available from: http://www.euro.who.int/__data/assets/pdf_file/0007/96451/E89814.pdf.
- McDaid D. Psychiatric remuneration systems in Europe: an overview. Die Psychiatrie. 2011;8(1):9–15.
- OECD. StatExtracts. Health expenditure and financing: % gross domestic product [Internet]. Paris: The Organisation for Economic Co-operation and Development (OECD); 2012 [updated 2013 May 2; cited 2013 Dec 12]. Available from: http://stats.oecd.org.
- OECD. StatExtracts. Health Care Resources: Hospital beds [Internet]. Paris: The Organisation for Economic Co-operation and Development (OECD); 2012 [updated 2013 May 2; cited 2013 Dec 12]. Available from: http://stats.oecd.org.
- FSO. Kosten und Finanzierung des Gesundheitswesens. Neuchatel: Swiss Federal Statistical Office (FSO); 2010.
- OECD. StatExtracts. Health Care Utilisation: Average length of stay by diagnostic categories 2012 [Available from: http://stats.oecd.org.
- Obsan. Stationäre Psychiatrie in der Schweiz 2000–2006. Neuchatel: Swiss Health Observatory; 2008.
- GDKtZH. Psychiatrieplanung 2012. 1.Teil Versorgungsbericht Psychiatrie [Internet]. Zürich: Gesundheitsdirektion Kanton Zürich; 2011 [cited 2013 Dec 12]. Available from: http://www.gd.zh.ch/internet/gesundheitsdirektion/de/themen/behoerden/spitalplanung_spitallisten/psychiatrie/archiv_projekt_psychiatrieplanung_2012.html.
- Thornicroft G, Tansella M. Components of a modern mental health service: a pragmatic balance of community and hospital care: overview of systematic evidence. Br J Psychiatry. 2004;185:283–90.
- Knapp M, McDaid D, Ammadeo F, Constantopoulos A, Oliveira MD, Salvador-Carulla L, et al. Financing mental health care in Europe. J Ment Health. 2007;16(2):167–80.
- Lave R, Frank G. Effect of the structure of hospital payment on length of stay. Health Serv Res 1990;25(2):327–47.
- Schuhmacher DN, Namerow MJ, Parker B, Fox P, Kofie V. Prospective payment for psychiatry – feasability and impact. N Engl J Med. 1986;315(21):1331–6.
- Taube CA, Goldman HH, Lee ES. Use of specialty settings in constructing DRGs. Arch Gen Psychiatry. 1988;45(11):1037–40.
- Taube C, Lee ES, Forthofer RN. DRGs in psychiatry: An empirical evaluation. Med Care. 1984;22(7):597–610.
- Rupp A, Steinwachs DM, Salkever DS. Hospital payment effects on acute inpatient care for mental disorders. Arch Gen Psychiatry. 1985;42(6):552–5.
- Frank RG, Lave JR. A comparison of hospital responses to reimbursement policies for Medicaid psychiatric patients. Rand J Econ. 1989;20(4):588–600.
- Lave JR, Frank RG, Taube C, Goldman H, Rupp A. The early effects of Medicare’s prospective payment system on psychiatry. Inquiry. 1988;25(3):354–63.
- Rupp A, Steinwachs D, Salkever D. The effect of hospital payment method on the pattern and cost of mental health. Hosp Community Psych. 1984;35(5):456–9.
- Lave J. Developing a Medicare prospective payment system for inpatient psychiatric care. Health Affair. 2003;22(5):97–109.
- De Agostini P, Bomizzato P, Ammadeo F, Bisoffi G, Perali F, Tansella M. For a more rational funding system of mental health services. Analyses of costs for service supplied by community mental health services during a 7–year period. Epidemiol Psychiatr Soc. 2001;10(3):163–79. Italian.
- Salvador-Garulla L, Garrido M, McDaid D, Haro JM. Financing mental health care in Spain. Context and critical issues. Eur J Psychiat. 2006;20(1):29–44.
- Zechmeister I, Oesterle A, Denk P, Katschnig H. Incentives in financing mental health care in Austria. J Ment Health Policy Econ. 2002;5(3):121–9.
- Frank RG, Lave JR. Per case prospective payment for psychiatric inpatients: an assessment and alternatives. J Health Polit Policy Law. 1986;11(1):83–96.
- Frank RG, Lave JR. The effect of benfit design on the length of stay of medicaid psychiatric patients. JHR. 1986;21(3):321–37.
- OFR. Federal Register, Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System – Update for Fiscal Year Beginning October 1, 2013 (FY 2014) [Internet]: Office of the Federal Register (OFR); 2013 [cited 2013 Dec 12]. Available from: https://www.federalregister.gov/articles/2013/08/01/2013–18445/medicare-program-inpatient-psychiatric-facilities-prospective-payment-system-update-for-fiscal-year.
- Klose P, Dirschedl P, Mohrmann M. Fallpauschalen in der Krankenhaus-Psychiatrie der USA. Das Inpatient Psychiatric Facility Prospective Payment System (IPF PPS). Gesundheitswesen. 2010;72(8–9):487–91.
- InEK. PEPP-Entgeltsystem 2013 [Internet]: Institut für das Entgeltsystem im Krankenhaus (InEK); 2013 [cited 2013 Dec 12]. Available from: http://www.g-drg.de/cms/PEPP-Entgeltsystem_2013.
- GDKtZH. PSYREC-KTR-Handbuch [Internet]. Zurich: Department of Health Canton of Zurich; 2007 [cited 2013 Dec 12]. Available from: http://www.gd.zh.ch/internet/gesundheitsdirektion/de/themen/institutionen/spitaeler_kliniken/handbuecher_vorgaben_erhebung.html.
- Frick U, Winfried B, Binder H. Hospital financing in inpatient psychiatry via DRG-based prospective payment – The Salzburg experience. Psychiatr Prax. 2001;28(Suppl 1):55–62.
- Warnke I, Rössler W. Length of stay by ICD-based diagnostic groups as basis for the remuneration of psychiatric inpatient care in Switzerland. Swiss Med Wkly. 2008;138(35–36):520–7.
- Warnke I, Rössler W, Herwig U. Does psychopathology at admission predict the length of stay of inpatient stay in psychiatry? Implications for financing psychiatric services. BMC Psychiatry. Epub 2011 Jul 29; 11: 120. DOI: 10.1186/1471–244X-11–120.
- Becker T, Kilian R. Psychiatric services for perople with severe mental illness across western Europe: what can be generalized from current knowledge about differences in provision, costs and outcomes of mental health care? Acta Psychiatr Scand. 2006;Suppl(429):9–16.
- Long MJ, Fleming ST, Chesney JD. The impact of diagnosis related group profitability on the skimming and dumping of pschiatric diagnosis related groups. Int J Soc Psychiatry. 1993;39(2):108–20.
- IOM. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academic Press: Institute of Medicine; 2001.
- GDKtZH. Zürcher Psychiatrieplanung 2012. 2.Teil: Strukturbericht Psychiatrie [Internet]. Zürich: Gesundheitsdirektion Kanton Zürich; 2011 [cited 2013 Dec 12]. Available from: http://www.gd.zh.ch/internet/gesundheitsdirektion/de/themen/behoerden/spitalplanung_spitallisten/psychiatrie.html http://www.gd.zh.ch/internet/gesundheitsdirektion/de/themen/behoerden/spitalplanung_spitallisten/psychiatrie.htm.
- RCPSYCH. Health of the Nation Outcome Scales [Internet]. London: Royal College of Psychiatrists; 2013 [cited 2013 Dec 12]. Available from: http://www.rcpsych.ac.uk/crtu/healthofthenation.aspx.
- MacDonald AJ, Elphick M. Combining routine outcomes measurement and “Payment by Results”: will it work and is it worth it? Br J Psychiat. 2011;199(3):178–9.
- Sikka R. Pay for performance in emergency medicine. Ann Emerg Med. 2007;49(6):756–61.
- Bremer RW, Scholle SH, Keyser D, Houtsinger JV, Pincus HA. Pay for performance in behavioral health. Psychiat Serv. 2008;59(12):1419–29.