DRG implementation in
Estonian health care model –
hospital perspective
Teele Orgse
4th Nordic Casemix Conference
June 4th 2010 Helsinki
The Republic of Estonia
• Parliamentary republic, president elected for 5
years (Mr. Toomas Hendrik Ilves)
• Official language – Estonian
• Coastline – 3794 km with 1521 islands
• Total area – 45 227 km2
• Population – 1 370 000 (Estonians 65%,
Russians 28%, Ukrainians 3%, Belorussians
1%, Finns 1%, other 2%)
• Independent since 24.02.1918, occupied by the
Soviet Union 1940, regained the independence
on 20.08.1991. Member of the European Union
since May 1st 2004.
• We have been here since 6500 BC!
Background – Soviet
heritage
• Centralized
• state-controlled
• over-capacitated provider
network (120 hospitals with 18
000 beds)
• Polyclinics
• budget financed
Background - reforms
• Began in the end of 1980s
• Economic collapse, high inflation and
political clutter – the aim was:
– to improve the efficiency and quality of health care
system
– to meet the needs of a small country and its population
• Decentralization of primary and hospital care
to local administrative level
• Elimination of special systems
• Separation of powers
• January 1st 1992: Health Insurance Law
– From tax-based to insurance-based
• Hospital network reorganization
• Health care providers – operating under
private law
Hospital Master Plan
Regionalism
Golden Circle
Financing
Co-payment
21%
Others
3%
Municipalities
1%
Central
government
9%
Earmarked
payroll tax
13%
66%
Contracting
Need
assessment
Quarterly
assessment
4-year financial
prognosis
Designing of
budget
Contracting
The most cost-efficient system in Europe
because of the contracting system. The supreme
winner in the 2007 and 2008 BFB (bang-for-thebuck) scores (Euro Health Consumer Index 2008
report).
Contract
Health care services list
• Calculated by the EHIF, consulted with specialists and
hospitals
• Over 130 pages
• Lists every
detailed service
– coded + priced
The BILL
• Fee-for-service:
– Service + service + service = € € €
• Hospitals analyse and manage
contracts
• Capped contracts
DRG-s in Estonia
• Implemented in 2004
• There were a few articles about
what DRGs are (Habicht)
• Some presentations
• “Somehow infiltrated”
• Starting from 10%/90% to
70%/30% today
The BILL
• Fee-for-service:
– Service + service + service = € € €
• Hospitals analyse and manage
contracts
• Capped contracts
• Bill = services 30% +
DRG price 70%
Conclusion?
• Confusion
• Loss of transparency
Hospital “study”
• 2 hospitals regularly analyze the impact of
DRGs
• 1 hospital uses special program – Datawell
Visual DRG Pro
• 7 years after implementation basic
calculation principles still need to be
introduced
• EHIF finances over 90% of the hospital
budget
– Pärnu Hospital 10,2 M € (45%)
– 70% 7,1M €
Correcting
• Is labour with suturation still
labour or is it a complication?
• Is a chronically ill heart failure
patient a heart failure patient or
a patient with heart rhytm
problems?
• Is stenocardia the main problem
or is morbus ischaemicus
cordis?
Classification
• Official guidelines:
– Gynecology and obstetrics 2005
– Hematology 2006
• ICD-10
– Doctors education
– “Most resourceful diagnose”
• Better statistics if dealth with
Case study - Pärnu
Hospital
• Around 15 000 bills that concern
DRG
– 2 300 don’t classify
– Over 50% of bills are covered by
22 DRGs
800
467
700
373
600
381
DRG-de arv
500
060
014
400
070B
300
098B
039
200
138
100
364
383
0
2005
2006
2007
2008
2009
450
243
400
184B
350
222
DRG-de arv
300
209A
250
127
200
380
150
121
100
059
270
50
284
0
2005
2006
2007
2008
2009
395
Are prices fair?
2005 – 2006
101%
2006 – 2007
101%
2007 – 2008
119%
2008 – 2009
101%
2009 - 2010
101%
300,000
467
200,000
Summa kroonides
373
381
100,000
060
014
070B
0
2005
2006
2007
2008
2009
098B
-100,000
039
138
364
-200,000
383
-300,000
600,000
243
400,000
184B
Summa kroonides
200,000
222
209A
0
2005
2006
2007
2008
2009
127
-200,000
380
-400,000
-600,000
-800,000
121
059
270
284
-1,000,000
395
-1,200,000
DRG 182
• 2006-2010 DRG billing in infectious
diseases department always negative
• DRG 182 one of the most usual (1-3)
• 01.01.2010– 21.05.2010 42 cases
- negative financial aspect 44 710 EEK
- negative 19
- positive 23
• Negative in cases with over 5 days
admission
DRG 225
• 2006-2010 DRG billing in orthopedics
department always negative
• DRG 225 one of the most usual (4-5)
• 01.01.2010– 21.05.2010 16cases
- negative financial aspect 29 269 EEK
- negative 13
- positive 3
• Negative in higher class operations
Conclusion
• DRGs are part of hospital
financing system
• Hospitals don’t have resources
or will or know-how or a reason
to analyze
• Made the system less
transparent
• There is so much information
that could be used and we are
moving towards that
Tervist!