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Description of Case-Mix Adjusters by the Severity of Illness Working Group of The Society of Hospital Epidemiologists of America (SHEA)

Published online by Cambridge University Press:  07 February 2022

Peter A. Gross ,
B. Eugene Beyt Jr. ,
Michael D. Decker ,
Richard A. Garibaldi ,
Walter J. Hierholzer Jr. ,
William R. Jarvis ,
Elaine Larson ,
Bryan Simmons ,
William E. Scheckler  and
Lorraine M. Harkavy
Peter A. Gross*
Affiliation:
Hackensack Medical Center, Hackensack, New Jersey and New Jersey Medical School, Newark, New Jersey
B. Eugene Beyt Jr.
Affiliation:
Louisiana State University School of Medicine, New Orleans, LA
Michael D. Decker
Affiliation:
Vanderbilt University School of Medicine, Nashville, Tennessee
Richard A. Garibaldi
Affiliation:
University of Connecticut Health Center, Farmington, Connecticut
Walter J. Hierholzer Jr.
Affiliation:
Yale-New Haven Hospital and Yale University School of Medicine, New Haven, Connecticut
William R. Jarvis
Affiliation:
Hospital Infections Program, Centers for Disease Control, Atlanta, Georgia
Elaine Larson
Affiliation:
The Johns Hopkins University School of Nursing, Baltimore, Maryland
Bryan Simmons
Affiliation:
Methodist Hospitals and University of Tennessee School of Medicine, Memphis, Tennessee
William E. Scheckler
Affiliation:
St. Marys Hospital and University of Wisconsin Medical School, Madison, Wisconsin
Lorraine M. Harkavy
Affiliation:
Association for Practitioners in Infection Control, Potomac, Maryland
*
Department of Internal Medicine, Hackensack Medical Center, 30 Prospect Avenue, Hackensack, NJ 07601
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Abstract

Hospitals, insurance companies, and federal and state governments are increasingly concerned about reducing patient cost expenditures while maintaining high quality patient care. One method of reducing expenditures has been to tie hospital reimbursement with a prospective payment system based on diagnosis-related groups (DRGs). However, reimbursement under the DRG system is not acceptable for all patients in all hospitals because it is neither an accurate predictor of costs nor of clinical outcome. This deficiency poses significant problems for hospitals because DRGs are used nationwide as the prospective payment system for inpatients covered by Medicare. Several case-mix adjusters have been proposed to modify DRGs to improve their accuracy in predicting costs and outcome. We reviewed five of the most widely available indices: Acute Physiologic and Chronic Health Evaluation (APACHE II), Coded Disease Staging, Computerized Severity Index (CSI), Medical Illness Severity Group System (MEDISGROUPS), and Patient Management Categories (PMC). Recommendations for the use of a single case-mix adjuster cannot be made at this time because all indices have not been compared in sufficiently diverse settings and because some are better predictors of costs while others are better predictors of clinical outcome. Hospital epidemiologists and other infection control practitioners should be informed about these indices and their potential applications as they expand their role beyond infection control problems to issues concerning cost containment, quality assurance, and reimbursement.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 9 , Issue 7 , July 1988 , pp. 309 - 316
Copyright
Copyright © The Society for Healthcare Epidemiology of America 1988

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