Alfa D’Amato, Deputy Director, ABF TaskforceSusan Dunn, Manager, ABF Workstreams, ABF Taskforce

ABF TASKFORCEEmergency Department

Funding Model

ABF Taskforce

NHRA 2011 ObjectivesObjectives of the National Health Reforms – Broader than ABF

• Share the future cost of growth in the efficient price and service provision equally between the State and Commonwealth

• Establish a national consistent approach to activity based funding for public hospitals, with the provision for block funding smaller rural hospitals where required

• Ensure strong national standards to improve clinical safety and quality in hospitals and health care settings

• Enhance transparency on the performance of hospital and health care services.

National Health Reform Agreement Implementation of a nationally consistent Activity based funding

system for:

– admitted acute services, emergency department services and non-admitted patient services from July 2012

– mental health and sub and non-acute services from July 2013; and

Teaching Training and Research no later than 30 June 2018

Commonwealth will fund 45% of efficient growth from July 2014, increasing to 50% from July 2017.

Block Funded hospitals: Commonwealth will fund 45% of growth in efficient cost from July 2014, increasing to 50% from July 2017.

LHDs/SHNs

Australian Commission on Safety and Quality in

Health Care

National Health Performance

Authority

Independent Hospital Pricing

AuthorityNational Funding

Body

Ministry of Health

Data Provision by Health Departments Data Provision by Health Departments

National Minimum Data Set Reporting

Performance KPIse.g. Emergency

e.g. Elective Surgery

Patient Level Cost & Activity Data

Activity Targetse.g. Admitted Acute

e.g. Emergency

National Health Reform Act (NHRA)

National Minimum Data Set Reporting

Performance KPIse.g. Emergencye.g. Elective Surgery

Patient Level Cost & Activity Data

Activity Targetse.g. Admitted Acutee.g. Emergency

Independent Hospital Pricing Authority - IHPA An independent statutory authority established under

Commonwealth legislation (Dec 2011) as part of the National Health Reform Agreement (NHRA) reached by the Council of Australian Governments (COAG) in August 2011

Set in scope services, national efficient price (NEP $4808), set national efficient cost (NEC), set general guidelines

Guidelines may change in the future

May do audit in the future – therefore, need to be able to prove the source of data in WebNAP ie 150 Respiratory OOS in WebNAP corresponds to 150 OOS in IPM

State Accountability

System manager for the public hospital system

Negotiates with LHDs/SHNs about service volumes (targets) and locations to be delivered

Determines state funding contribution and total funding to each LHD/SHN. State price = $4471

Bears residual risk and meet costs of service delivery State remains majority funder of health services until 2063

when Commonwealth share finally reaches 50%BUT Role of the Independent Administrator may effect payments Local decision making - LHDs/SHNs responsible for allocation

of budgets to hospitals under Service Agreements

National Efficient Price (NEP)Interpreting the NEP

The NEP, as calculated by the IHPA, is based on the average cost of providing acute admitted services across Australia, but also applies to emergency and non-admitted services.

All cost weights are expressed as a single unit of measure being the National Weighted Activity Unit (NWAU). It provides a scale that identifies the relative measure of resource use of each public hospital service.

NEP Adjustments Indigenous - A patient based adjustment of 5%

LocationA patient based adjustment with three levels:

Outer regional 8.7%Remote 15.3%Very remote 19.4%

Calculation of Price$ (2012/13) = NEP x NWAU(12)NWAU(12) = URG_PriceWeight * (1+Aindig + Alocation))

Emergency Departments Classification System

Emergency Classification(1)Urgency Disposition Groups Classified to UDGs - Urgency Disposition Groups

– Classification developed by Dr George Jelinek (FACEM) in 1992 using WA hospitals data

– ED Role delineation 1 – 3A

– eg Batemans Bay, Sydney/Sydney Eye, Singleton

Requires correct classification of:

– Triage Category

– Disposition (mode of separation)

9

Emergency Classification (2)Urgency Related Groups Groups to URGs -

– Initially developed by Dr George Jelinek (FACEM) based on UDGs

– ED Role delineation 3B – 6

– eg Westmead, Prince Alfred, Liverpool

Requires correct classification of:

– Triage Category

– ED principal diagnosis

– groups to 27 Major Diagnostic Blocks

– Disposition (mode of separation)10

Urgency Disposition Groups

admitted non-admitted dead on arrival(URG 38)

did not wait(URG 73)

MDB 2A(URG 1)

MDB 3O(URG 2)

MDB 2B(URG 3)

MDB 1A/1B(URG 4)

MDB 3B(URG 5)

MDB 3A(URG 6)

MDB Other(URG 7)

triage 1 triage 2 triage 3 triage 4 triage 5

Emergency Department Classification System

Urgency Related Groups

URG Components

–Triage Category

–Disposition (mode of separation)

–ED principal diagnosis

URG 3 Admitted Triage 1 - Injury

URG Components:TriageDefinition:

Classification according to urgency of need for medical and nursing care, using the Australian Triage Scale.

Valid Triage Codes

– 1 Emergency Presentation

– 2 Emergency

– 3 Urgent

– 4 Semi urgent

– 5 Non urgent

URG Components:Disposition

Disposition Classes

• The URG classification system consists of 4 disposition classes that include:

– Non-admitted

– Admitted

– Dead on arrival

– Did not wait

Assignment to disposition class is dependent on ED Mode of Separation value

Code Domain Description

URG Components:DispositionCode ED Mode of Separation (disposition) Disposition

01 Admitted: To Ward/inpatient unit, not a Critical Care Ward Admitted

02 Admitted & discharged as inpatient within ED Non admitted

03 Admitted: Died in ED Died in ED

04 Departed: Treatment completed Non admitted

05 Departed: Transferred to another hospital without first being admitted to the hospital from which transferred

Transfer presentation

06 Departed: Did not wait Did not wait

07 Departed: Left at own risk Non admitted

08 Dead on Arrival Dead on Arrival

09 Departed: for other Clinical Service Location Non admitted

10 Admitted: To Critical Care Admitted

11 Admitted: Via Operating Suite Admitted

12 Admitted: Transferred to another hospital Transfer presentation

13 Admitted: Left at own risk Admitted

99 Registered in Error

Code Domain Description

URG Components:ED Diagnosis

•Diagnosis code maps to Major Diagnostic group•Acute bronchitis, unspecified

3B Respiratory system illness•Stroke, not specified as haemorrhage or infarction

3E Neurological illness•No diagnosis code = Moves to a UDG code

1A Poisoning, comatose1B Poisoning, conscious1C Drug reaction1D Alcohol/drug abuse and alcohol/drug induced mental disorders2A Injury, multiple sites2B Injury, single site2BA Injury, single site *minor (subset of MDB 2B)3A Circulatory system illness3B Respiratory system illness3C Digestive system illness3D Urological illness3E Neurological illness

Major Diagnostic Blocks

Recording Diagnosis 2012-13

Non-admitted patient

ED component

Time of arrival at ED Time of departure from ED

Applicable period of reported ED diagnosisED diagnosis assigned

URG Components:ED Diagnosis

Recording Diagnosis – 2012-13

Admitted to ward patient

ED component Ward component

Time of arrival at ED Time of departure from ED to ward

Applicable period of reported ED diagnosisED diagnosis assigned

Time of departureFrom hospital

Applicable period of reported principal diagnosis

Principal diagnosis assigned

URG Components:ED Diagnosis

URG/UDG AR-DRG

URG classification: Diagnosis code = SeizureURG classification can be any of these depending on the Triage category and the disposition (ED Separation mode)

Each of these URG codes will have a separate funding amount attached to it based on the National Weighted Activity Unit value.

Example of URG Funding Scenario 1 Major Trauma patient (non-aboriginal from a remote area) is brought in

via ambulance to a regional emergency department, & triaged as a category 1. Patient is stabilised, and a decision to transfer is made. Patient is subsequently transferred to a major tertiary major trauma centre. On discharge, patient ED principal diagnosis recorded as Traumatic subdural haemorrhage

Key data items:

Triage 1ED Mode of separation: Departed: Transferred to another hospital without first

being admitted to the hospital from which transferred (Non Admitted)Diagnosis –Traumatic subdural haemorrhage (MDB 2A) Injury, multiple

sitesAssigned -URG Group 39 Non Admitted Triage 1 – All MDB groupsATSI –No

Very Remote –Yes (19.4%)

URG Funding Scenario 1 (cont)Price:

NWAU(12) = URG_39 PriceWeight * (1+Aindig + Alocation))

= 0.2203 * (1 + 0 + 0.194)

= 0.2630382

$ (2012/13) = State price x NWAU(12)

= $4,471 x 0.2630382

= $1,176.04

0

200

400

600

800

1000

1200

1400

1600

2011-12 Emergency URG 39 Non-Admitted Triage 1 - All MDB GroupsAverage Cost - Peer Groups A1 to C1 - Draft

Average Cost of URG 39 per ED Presentation

Example of URG Funding Scenario 2

Major Trauma patient (non-aboriginal from a remote area) from a regional emergency department is received at a major trauma centre. Patient is brought into the ED, triaged a category 1, assessed , CT scan is ordered, reviewed and a decision is made to transfer the patient to theatre. Patient is subsequently transferred to a ward. On ED discharge, patient ED principal diagnosis recorded as Traumatic subdural haemorrhage (S065).

Key data items:

Triage 1

ED Mode of separation 11 Admitted: Via Operating Suite (admitted)

Diagnosis Traumatic subdural haemorrhage (MDB 2A) Injury, multiple sites

Assigned - URG 3 Admitted Triage 1 -Injury

ATSI – No

Very Remote – Yes (19.4%)

URG Funding Scenario 2 (cont)Price:

NWAU(12) = URG 3_PriceWeight * (1+Aindig + Alocation))

= 0.3313 * (1 + 0 + 0.194)

= 0.3955722

$ (2012/13) = State price x NWAU(12)

= $4,471 x 0.3955722

= $1,768.60

Average Cost of URG 3 per ED Presentation

0

500

1,000

1,500

2,000

2,500

3,000

3,500

2011-12 Emergency URG 3 Admitted Triage 1 - InjuryAverage Cost - Peer Groups A1 to C1 - Draft

Further ABF Information

Resource kit available: http://internal.health.nsw.gov.au/communications/funding_reform/resources.html

Email: abf@doh.health.nsw.gov.au