Severity and risk adjusting relating to obstetric outcomes, DRG assignment, and reimbursement.
Obstetric risk has important implications for reporting and benchmarking quality in today's managed health care environment. Administrative data, including diagnosis related group (DRG) information collected by hospitals, is used by payers and governmental groups for reimbursement, monitoring quality, and setting financial rates. Obstetric conditions that affect the patient experience are coded but do not often contribute to the overall DRG assignment. This strategy, therefore, may provide comparisons that are misleading to consumers and payers. Additionally, financial rates often do not provide adequate reimbursement for the cost incurred in caring for high-risk patients. Finally, risk prediction strategies have historically been used to both identify vulnerable patients for early management and make more equitable comparisons of groups of patients.
Fleschler
R G
RG
University of Texas at Austin, School of Nursing, USA. rfrn@flash.net
Knight
S A
SA
Ray
G
G
D000328:Adult; D019985:Benchmarking; D015897:Comorbidity; D003953:Diagnosis-Related Groups / Q000145:classification* / Q000191:economics; D005260:Female; D006302:Health Services Research; D006801:Humans; D008329:Managed Care Programs / Q000458:organization & administration; D016389:Maternal-Child Nursing; D011237:Predictive Value of Tests; D011247:Pregnancy; D011248:Pregnancy Complications / Q000145:classification* / Q000191:economics; D011256:Pregnancy Outcome / Q000191:economics* / Q000453:epidemiology*; D018566:Pregnancy, High-Risk; D012051:Reimbursement Mechanisms; D020379:Risk Adjustment / Q000458:organization & administration*; D018570:Risk Assessment; D012720:Severity of Illness Index; D014481:United States