Following Victoria's lead, the past four years have seen both the introduction and the practical application of casemix in most States and Territories in Australia. At the same time there has been refinement of the acute-care classification, development of classifications for subacute care, ambulatory and emergency care, and the recent implementation of the Australian modification of the International classification of diseases and related health problems, 10th revision (ICD-10-AM). Although only a small core of clinicians were involved in these developmental processes, many have now experienced working in a casemix-funded environment. It is time for these clinicians to comment on the perceived benefits and pitfalls of casemix and their vision for casemix in the future.
This second MJA casemix supplement presents these viewpoints. Leading clinicians in the public and private sectors and academics from a range of disciplines discuss the impact and future of casemix in Australia. The intent is not to cover all aspects of casemix, nor to discuss the impact of casemix funding on every discipline, but rather to explore key areas.
In the evolutionary phase of casemix since 1994, many clinicians, and particularly clinical managers, have focused their attention on the complexities of casemix and on protecting immediate interests, be these specific to departments, specialties or hospitals. The experience of casemix funding of acute-care services has varied in different States, and refinements are still needed to address inappropriate incentives and ensure fairer funding. It is still not clear what longer term consequences the States' different casemix-funding models will have on the healthcare system as a whole, on hospital funding, teaching and research and, most importantly, on patient care.
The Aboriginal and Torres Strait Islander Casemix Study (Fisher et al), and Ruben and Fisher's study of the impost of the current casemix classification on Aboriginal and Torres Strait Islander children, highlight the importance of analysing the application of national casemix classifications in communities with different population profiles. Many factors contribute to the higher resource requirements of Aboriginal and Torres Strait Islander patients, including length of hospital stay, younger age, multiple comorbidities and remote location. These studies clearly demonstrate deficiencies in the current acute-care classification and funding models for health services for indigenous people, and emphasise the need for increased funding for hospitals with a high proportion of these patients.
In the broader context, Duckett compares the different States' casemix funding policies and points out the advantages of sharing experiences across State borders in order to develop the best possible casemix-funding model. Of concern is the disparity in costing between the States, suggesting a need for standardisation in defining costs to minimise this potential inequality and facilitate national benchmarking. Phelan et al emphasise the role clinicians can play by increasing their understanding of how patient care is costed. This will allow them to set valid benchmarks and enhance the efficiency of their clinical services while maintaining and improving quality of care.
Casemix classifications are appropriate for describing the average patient, but these classifications still perform poorly in distinguishing illness severity in patients in specialist as opposed to general hospitals, or in specific patient groups such as children (Hanson et al). Age and other factors, for example the need for transfer of patients for specialised care (Butt and Shann), are used as proxies for illness severity and higher dependency instead of refining the classification.
The value of casemix for addressing the wider issues of healthcare reform has largely been hampered by the lack of suitable classifications. The development of a classification for subacute and non-acute care (AN-SNAP) that reflects the goals of management is a welcome step forward (Lee et al). This scheme will complement the current acute-care classification (AR-DRG-4). The strong clinical acceptance of AN-SNAP augurs well for its implementation. The long-awaited outpatient classification, beyond a simple clinic-based structure, continues to prove elusive (Cleary et al). The attempt at developing a patient-based classification has not been successful. To achieve further progress, the time may have come to adopt one of the State clinic-based classifications, such as the Victorian Ambulatory Classification, as a national standard.
Clinicians have expressed concern about the suitability of ICD-9-CM (International classification of diseases, 9th edition, clinical modification) to describe clinical practice and support data quality. The development and implementation of ICD-10-AM through the efforts of the National Centre for Classification in Health, and the Centre's commitment to working with clinicians, will pave the way forward to a more flexible and relevant Australian classification. An important feature of ICD-10-AM is the inclusion of a procedure classification based on the Commonwealth Medical Benefits Schedule, which can be used in both the public and private sectors (Roberts et al).
A strong case is made for the development of a distinct classification for nursing by Long and Mann and for allied health by Byron and McCathie. These classifications will facilitate meaningful benchmarking across services and enhance the use of casemix in monitoring quality of care and outcomes.
What is still lacking in casemix development is an emphasis on continuum of care. Furthermore, little attention has been paid to the way casemix should be used to improve patient care, or to its limitations in addressing patient outcomes and healthcare quality. The wider use of casemix in determining care paths and in utilisation review is now also emerging in both the public and private sectors, and needs closer clinical scrutiny. This changing focus is reflected in the range of articles in this supplement, and presents a challenge to clinicians from all disciplines (see Maxwell, on implications of the use of AN-DRGs in the private sector; and Hart and Wallace, on casemix and surgery).
The foundation of clinical practice is education and research. In its evolution, casemix has focused on core clinical requirements, but Phillips argues that a focus on teaching and research is urgently needed. He suggests that it may be time to promote outcome-based funding of teaching and research in the Australian healthcare system.
Surprisingly, so far only a relatively small group of clinicians has taken an active interest in casemix. In view of the impact casemix has had on clinical care, this is difficult to explain. There is a risk that this lack of participation by the broader clinical community not only could leave Australia with patient classification and funding systems with inadequate clinical relevance, but could also affect the financial stability of a range of clinical services, reduce clinical autonomy and potentially compromise quality of patient care.
The future lies not just in developing nationally consistent methods of classifying healthcare services and costs, but in determining how these methods can be applied to best suit the evolving model of healthcare and improve the quality of care provided to all groups of patients across the country. Clinicians need to be involved in this process.
Ralph M Hanson
Education Advisor to the Australian Casemix Clinical Committee
The New Children's Hospital, Sydney, NSW