eMJA Casemix Supplement: Casemix: the allied health response

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Casemix: moving forward

Casemix: the allied health response

Annette L Byron and Helen C F McCathie

MJA 1998; 169: S46-S47

Synopsis - Introduction - National Allied Health Casemix Committee (NAHCC) - Australian Allied Health Activity Classification - Allied health procedure codes - Coding challenges - Benchmarking - Future directions - References - Authors' details

Synopsis

Casemix has given allied health professionals the opportunity to review their approaches to patient care, contribute to reducing inpatient costs and improve quality of care.

The National Allied Health Casemix Committee was formed in 1993 to advance allied health participation in casemix. The Committee has taken the first step in establishing cost weights for allied health through the Australian Allied Health Activity Classification, which defines allied health inputs in terms of clinical care, clinical service management, teaching and training, and research.

Work is being done on generic classification of allied health inputs, and studies are examining what allied health activities are accounted for by DRGs and ICD-9-CM.

Allied health has taken up the challenge of casemix, but better access to information technology will enhance its continued contribution.

Introduction
The advent of casemix in Australia has provided allied health practitioners and managers with an opportunity to review their approaches to patient care, contribute to organisational goals of reducing inpatient costs, maximise reimbursement within funding rules, and improve the quality of patient care. Significant achievements have been made at local, State and national levels, despite deficiencies in both the systems and the technology supporting casemix implementation.
National Allied Health Casemix Committee (NAHCC)
The NAHCC was formed in 1993 to advance allied health participation in casemix. There are 14 professional member organisations of the NAHCC. Allied health casemix groups in all States and Territories are also represented. NAHCC has successfully completed major projects by focusing on areas of commonality, rather than difference. This has also occurred at the State level; for example, in South Australia cooperation between allied health, the South Australian Health Commission and information services staff led to agreement on the requirements for an allied health information management system.
The Reference Standards Project¹ undertaken by the NAHCC is the first step in developing Australian cost weights for allied health. The lack of appropriate infrastructure, including an agreement on what constitutes inputs and outputs of allied health services, has so far precluded their development. The allied health weights applied in AN-DRGs are a version of the Maryland weights (Maryland [USA] Health Services Cost Review Commission, 1993) crudely modified for Australian use and not reflecting Australian allied health practice.
Australian Allied Health Activity Classification2
The Australian Allied Health Activity Classification was an important outcome of the Reference Standards Project. The classification broadly defines inputs in terms of clinical care, clinical services management, teaching and training, and research. More specifically, clinical care is defined as all activities which can be attributed to an individual patient, group or community, thus eliminating the inappropriate notions of "direct" and "indirect" care. This approach was taken up by other classification studies, including the Sub-Acute and Non-Acute Patient Casemix Classification Study.
The Reference Standards Project identified that occasions of service alone are not a satisfactory method of measuring outputs of allied health, and that further work in this area needs to be done.
Allied health procedure codes
In consultation with individual professional bodies and the NAHCC, the National Coding Centre (now the National Centre for Classification in Health [NCCH]) has identified discipline-specific interventions. The previous description of interventions within the ICD-9-CM procedures listing was extremely limited. Several disciplines submitted intervention codes and these were included in the July 1996 revision of ICD-9-CM. These codes have been refined and others added to the procedure listing in the recently developed Australian modification of ICD-10 (ICD-10-AM) (see Roberts et al). Future revision of the codes by the professions and the NCCH will ensure their adequacy in describing allied health inputs and their consistency in cross- discipline application.
Coding challenges
Projects by various allied health disciplines examining the extent to which their activities are accounted for by DRGs and the ICD-9-CM classification have shown considerable lack of agreement between classifications.
A study of the intensity of social-work time in an acute hospital³ found it to be more related to a patient's presenting psychosocial problems, but that these were influenced by diagnosis and complexity. A study for the Dietitians Association of Australia found that most, but not all, of the diagnostic terms used by dietitians in describing patient care matched with terms in ICD-9-CM.⁴ Items which could not be matched related to risk of malnutrition, risk of side effects of treatment or disease, or lack of diagnostic specificity of a particular disease. This study also established that dietitians, like many allied health practitioners, may see patients for reasons other than the principal reason for admission.
Despite limitations of existing casemix classifications to take allied health inputs into account, clear examples exist of allied health's contribution to casemix-funded organisations. In strategically managing occupational therapy services, an approach integrating DRGs with cost-benefit analysis was successful in decreasing average length of stay and improving quality of care.⁵ Community-based services developed by a rehabilitation team resulted in earlier discharge, improved continuity of care and a high level of patient satisfaction.⁶ Unfortunately, this service was not continued past the initial funding period, because hospital reimbursement would have been reduced if the alternative outpatient service continued.
By contrast, dietitians⁷ have shown that coding malnutrition as a comorbidity can alter DRG assignment and increase casemix reimbursement. More importantly, diagnosing malnutrition provides an opportunity to give appropriate and timely care, thus reducing the associated costs and length of stay.⁸
Benchmarking
Emphasis is often placed on the use of casemix as a budgeting tool, which overlooks its original use for measuring quality of clinical care.⁹ Casemix allows clinicians to compare inputs and outputs and measure outcomes in terms of quality, value and resource utilisation. A step towards this was the Best Practice in the Health Sector Program¹⁰ to promote international best practice standards of care and workplace organisation throughout the health sector. The program case studies provide an overview of the factors influencing the growth of allied health in Australia, in the context of principles of best practice.
In 1997, the Central Sydney Area Health Service established the National Allied Health Benchmarking Consortium. Its task was to identify methods of best practice by comparing allied health resource utilisation. The Consortium currently comprises seven teaching hospitals (three in New South Wales, and one each in Victoria, the Australian Capital Territory, Tasmania and South Australia). The objectives are to establish benchmarks of allied health resources at a national level, and to develop a framework to link benchmarks with inputs, processes and outcomes of allied health services and activities. In Phase I, baseline data were collected and are currently being analysed. Phase II, which will be conducted in close association with the NAHCC, will investigate the highest volume AN-DRGs with allied health inputs and selected outcomes.
Future directions
Allied health has taken up the challenge of casemix, but better access to information technology will enhance its continued contribution. Many allied health departments still rely on manual data collection to guide decision making. Access to hardware must be extended, and allied health information management systems interfacing with hospital decision support systems must be developed. Moreover, consistent application of classifications, such as the Australian Allied Health Activity Classification, will improve understanding of allied health inputs at the local, State and Territory, and national level. This will provide a platform for costing of allied health, and for developing allied health service weights. In addition, improved information systems will also support the allied health service structures that best manage human resources, meet the needs of smaller referring clinical units, maintain an appropriate skill mix of practitioners, and support training of undergraduates.
Interest in casemix among allied health practitioners has been steadily growing. The development of new classifications, such as the Australian National Sub-Acute Non-Acute Patient (AN-SNAP) Casemix Classification (see Lee et al) and the Mental Health Classification and Service Costs (MH-CASC), have further involved allied health professionals working in rehabilitation, mental health and other settings outside acute care. Moreover, community practitioners are becoming casemix-aware with the development of the Community Health Information Management Enterprise (CHIME), which is responsible for the National Codeset Project for community-based health services.
References

The National Allied Health Casemix Committee. Report to the Commonwealth Department of Health and Family Services on the development of National Reference Standards for allied health disciplines -- clinical terms and minimum data set. Melbourne: The National Allied Health Casemix Committee, 1997.
Australian Allied Health Classification System: Version 1. Melbourne: The National Allied Health Casemix Committee, 1997.
Badger J, Cleak H, Haywood M. Factors affecting the intensity of social work time in an acute hospital. Allied health and casemix: towards 2000. Melbourne: The National Allied Health Casemix Committee, 1996; 23-27.
Barrington V. The development and classification of dietetic diagnoses and interventions. Allied health and casemix: towards 2000. Melbourne: The National Allied Health Casemix Committee, 1996: 20-22.
Brandis S. An AN-DRG approach to planning occupational therapy services. Allied health and casemix: towards 2000. Melbourne: The National Allied Health Casemix Committee, 1996: 11-14.
Brandis S. The frustration of rehabilitation -- why quality doesn't pay. Proceedings of the Ninth Casemix Conference in Australia; 1997 Sep 7-10; Brisbane. Canberra: Commonwealth Department of Health and Family Services, 1997.
Ferguson M, Capra S, Bauer J, Banks M. Coding for malnutrition enhances reimbursement under casemix-based funding. Aust J Nutr Diet 1997; 54: 102-108.
Funk KL, Ayton CM. Improving malnutrition documentation enhances reimbursement. J Am Diet Assoc 1995; 95: 468-475.
Fetter RB. The history and development of diagnosis-related groups. Proceedings of the Eighth Casemix Conference in Australia; 1996 Sep 16-18; Sydney. Canberra: Commonwealth Department of Health and Family Services, 1996.
Commonwealth Department of Health and Family Services. Australian health organizations taking up the best practice challenge: the Best Practice in the Health Sector Program: case studies of the funded projects. Canberra: AGPS, 1996.

Authors' details
National Allied Health Casemix Committee, Melbourne, VIC.
Annette L Byron, BSc, BND, MBA, Chairperson, NAHCC; Chief Clinical Dietitian, Nutrition and food Services, Royal Adelaide Hospital, Adelaide, SA.
Helen C F McCathie, PhD, Executive member, NAHCC; Area Director of Psychology, Central Sydney Area Health Service, Concord Repatriation General Hospital, Sydney, NSW 2139.
Reprints: Ms A L Byron, Nutrition and food Services, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000.
E-mail: abyronATnadmin.rah.sa.gov.au

Go to the next article . . .
Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company.
Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>".
<URL: http://www.mja.com.au/> © 1998 Medical Journal of Australia.

Synopsis
	Casemix has given allied health professionals the opportunity to review their approaches to patient care, contribute to reducing inpatient costs and improve quality of care. The National Allied Health Casemix Committee was formed in 1993 to advance allied health participation in casemix. The Committee has taken the first step in establishing cost weights for allied health through the Australian Allied Health Activity Classification, which defines allied health inputs in terms of clinical care, clinical service management, teaching and training, and research. Work is being done on generic classification of allied health inputs, and studies are examining what allied health activities are accounted for by DRGs and ICD-9-CM. Allied health has taken up the challenge of casemix, but better access to information technology will enhance its continued contribution.
Introduction
	The advent of casemix in Australia has provided allied health practitioners and managers with an opportunity to review their approaches to patient care, contribute to organisational goals of reducing inpatient costs, maximise reimbursement within funding rules, and improve the quality of patient care. Significant achievements have been made at local, State and national levels, despite deficiencies in both the systems and the technology supporting casemix implementation.
National Allied Health Casemix Committee (NAHCC)
	The NAHCC was formed in 1993 to advance allied health participation in casemix. There are 14 professional member organisations of the NAHCC. Allied health casemix groups in all States and Territories are also represented. NAHCC has successfully completed major projects by focusing on areas of commonality, rather than difference. This has also occurred at the State level; for example, in South Australia cooperation between allied health, the South Australian Health Commission and information services staff led to agreement on the requirements for an allied health information management system. The Reference Standards Project¹ undertaken by the NAHCC is the first step in developing Australian cost weights for allied health. The lack of appropriate infrastructure, including an agreement on what constitutes inputs and outputs of allied health services, has so far precluded their development. The allied health weights applied in AN-DRGs are a version of the Maryland weights (Maryland [USA] Health Services Cost Review Commission, 1993) crudely modified for Australian use and not reflecting Australian allied health practice.
Australian Allied Health Activity Classification2
	The Australian Allied Health Activity Classification was an important outcome of the Reference Standards Project. The classification broadly defines inputs in terms of clinical care, clinical services management, teaching and training, and research. More specifically, clinical care is defined as all activities which can be attributed to an individual patient, group or community, thus eliminating the inappropriate notions of "direct" and "indirect" care. This approach was taken up by other classification studies, including the Sub-Acute and Non-Acute Patient Casemix Classification Study. The Reference Standards Project identified that occasions of service alone are not a satisfactory method of measuring outputs of allied health, and that further work in this area needs to be done.
Allied health procedure codes
	In consultation with individual professional bodies and the NAHCC, the National Coding Centre (now the National Centre for Classification in Health [NCCH]) has identified discipline-specific interventions. The previous description of interventions within the ICD-9-CM procedures listing was extremely limited. Several disciplines submitted intervention codes and these were included in the July 1996 revision of ICD-9-CM. These codes have been refined and others added to the procedure listing in the recently developed Australian modification of ICD-10 (ICD-10-AM) (see Roberts et al). Future revision of the codes by the professions and the NCCH will ensure their adequacy in describing allied health inputs and their consistency in cross- discipline application.
Coding challenges
	Projects by various allied health disciplines examining the extent to which their activities are accounted for by DRGs and the ICD-9-CM classification have shown considerable lack of agreement between classifications. A study of the intensity of social-work time in an acute hospital³ found it to be more related to a patient's presenting psychosocial problems, but that these were influenced by diagnosis and complexity. A study for the Dietitians Association of Australia found that most, but not all, of the diagnostic terms used by dietitians in describing patient care matched with terms in ICD-9-CM.⁴ Items which could not be matched related to risk of malnutrition, risk of side effects of treatment or disease, or lack of diagnostic specificity of a particular disease. This study also established that dietitians, like many allied health practitioners, may see patients for reasons other than the principal reason for admission. Despite limitations of existing casemix classifications to take allied health inputs into account, clear examples exist of allied health's contribution to casemix-funded organisations. In strategically managing occupational therapy services, an approach integrating DRGs with cost-benefit analysis was successful in decreasing average length of stay and improving quality of care.⁵ Community-based services developed by a rehabilitation team resulted in earlier discharge, improved continuity of care and a high level of patient satisfaction.⁶ Unfortunately, this service was not continued past the initial funding period, because hospital reimbursement would have been reduced if the alternative outpatient service continued. By contrast, dietitians⁷ have shown that coding malnutrition as a comorbidity can alter DRG assignment and increase casemix reimbursement. More importantly, diagnosing malnutrition provides an opportunity to give appropriate and timely care, thus reducing the associated costs and length of stay.⁸
Benchmarking
	Emphasis is often placed on the use of casemix as a budgeting tool, which overlooks its original use for measuring quality of clinical care.⁹ Casemix allows clinicians to compare inputs and outputs and measure outcomes in terms of quality, value and resource utilisation. A step towards this was the Best Practice in the Health Sector Program¹⁰ to promote international best practice standards of care and workplace organisation throughout the health sector. The program case studies provide an overview of the factors influencing the growth of allied health in Australia, in the context of principles of best practice. In 1997, the Central Sydney Area Health Service established the National Allied Health Benchmarking Consortium. Its task was to identify methods of best practice by comparing allied health resource utilisation. The Consortium currently comprises seven teaching hospitals (three in New South Wales, and one each in Victoria, the Australian Capital Territory, Tasmania and South Australia). The objectives are to establish benchmarks of allied health resources at a national level, and to develop a framework to link benchmarks with inputs, processes and outcomes of allied health services and activities. In Phase I, baseline data were collected and are currently being analysed. Phase II, which will be conducted in close association with the NAHCC, will investigate the highest volume AN-DRGs with allied health inputs and selected outcomes.
Future directions
	Allied health has taken up the challenge of casemix, but better access to information technology will enhance its continued contribution. Many allied health departments still rely on manual data collection to guide decision making. Access to hardware must be extended, and allied health information management systems interfacing with hospital decision support systems must be developed. Moreover, consistent application of classifications, such as the Australian Allied Health Activity Classification, will improve understanding of allied health inputs at the local, State and Territory, and national level. This will provide a platform for costing of allied health, and for developing allied health service weights. In addition, improved information systems will also support the allied health service structures that best manage human resources, meet the needs of smaller referring clinical units, maintain an appropriate skill mix of practitioners, and support training of undergraduates. Interest in casemix among allied health practitioners has been steadily growing. The development of new classifications, such as the Australian National Sub-Acute Non-Acute Patient (AN-SNAP) Casemix Classification (see Lee et al) and the Mental Health Classification and Service Costs (MH-CASC), have further involved allied health professionals working in rehabilitation, mental health and other settings outside acute care. Moreover, community practitioners are becoming casemix-aware with the development of the Community Health Information Management Enterprise (CHIME), which is responsible for the National Codeset Project for community-based health services.
References
	The National Allied Health Casemix Committee. Report to the Commonwealth Department of Health and Family Services on the development of National Reference Standards for allied health disciplines -- clinical terms and minimum data set. Melbourne: The National Allied Health Casemix Committee, 1997. Australian Allied Health Classification System: Version 1. Melbourne: The National Allied Health Casemix Committee, 1997. Badger J, Cleak H, Haywood M. Factors affecting the intensity of social work time in an acute hospital. Allied health and casemix: towards 2000. Melbourne: The National Allied Health Casemix Committee, 1996; 23-27. Barrington V. The development and classification of dietetic diagnoses and interventions. Allied health and casemix: towards 2000. Melbourne: The National Allied Health Casemix Committee, 1996: 20-22. Brandis S. An AN-DRG approach to planning occupational therapy services. Allied health and casemix: towards 2000. Melbourne: The National Allied Health Casemix Committee, 1996: 11-14. Brandis S. The frustration of rehabilitation -- why quality doesn't pay. Proceedings of the Ninth Casemix Conference in Australia; 1997 Sep 7-10; Brisbane. Canberra: Commonwealth Department of Health and Family Services, 1997. Ferguson M, Capra S, Bauer J, Banks M. Coding for malnutrition enhances reimbursement under casemix-based funding. Aust J Nutr Diet 1997; 54: 102-108. Funk KL, Ayton CM. Improving malnutrition documentation enhances reimbursement. J Am Diet Assoc 1995; 95: 468-475. Fetter RB. The history and development of diagnosis-related groups. Proceedings of the Eighth Casemix Conference in Australia; 1996 Sep 16-18; Sydney. Canberra: Commonwealth Department of Health and Family Services, 1996. Commonwealth Department of Health and Family Services. Australian health organizations taking up the best practice challenge: the Best Practice in the Health Sector Program: case studies of the funded projects. Canberra: AGPS, 1996.
Authors' details
	National Allied Health Casemix Committee, Melbourne, VIC. Annette L Byron, BSc, BND, MBA, Chairperson, NAHCC; Chief Clinical Dietitian, Nutrition and food Services, Royal Adelaide Hospital, Adelaide, SA. Helen C F McCathie, PhD, Executive member, NAHCC; Area Director of Psychology, Central Sydney Area Health Service, Concord Repatriation General Hospital, Sydney, NSW 2139. Reprints: Ms A L Byron, Nutrition and food Services, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000. E-mail: abyronATnadmin.rah.sa.gov.au

	Go to the next article . . . Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1998 Medical Journal of Australia.