Medicare: Refinement of Diagnosis Related Groups Needed to Insure Payment Equity

摘要

In fiscal year 1986, Medicare paid hospitals about $45.6 billion for inpatient hospital services. About $35 billion was paid under the Medicare prospective payment system (PPS). PPS pays hospitals a fixed, predetermined amount for each Medicare beneficiary discharged from a hospital. The amount of the payment for a beneficiary depends upon the diagnosis related group (DRG) that the patient is classified under. For PPS to work as intended it is essential that DRGs group patients with similar resource needs. Because of the importance of DRGs to PPS, GAO evaluated the DRG case classification system as a means of grouping patients for payment purposes. Specifically, GAO's objectives were to (1) measure the variations in the level of resources required to treat patients within the DRGs, (2) determine if hospitals get an equal mix of high- and low-cost patients in DRGs where a wide variation in resource requirements exists, and (3) determine if hospital characteristics, such as bed size and rural or urban location, are systematically related to whether a hospital receives patients with higher- or lower-than-average treatment costs within the DRGs.