How to Survive PBRHow to Survive PBR

Heather LewisHeather LewisDirector of FinanceDirector of Finance

Robert Jones and Agnes Hunt Robert Jones and Agnes Hunt Orthopaedic NHS TrustOrthopaedic NHS Trust

Surviving PBRSurviving PBR

Background IssuesBackground Issues

Current PBR and the futureCurrent PBR and the future

What we get paid forWhat we get paid for

BackgroundBackground

Payment basis is national tariffPayment basis is national tariff Healthcare Resource Groups are ISO-Healthcare Resource Groups are ISO-

resourcedresourced Coding determines which HRG Coding determines which HRG

procedures falls within – OPCS4.3procedures falls within – OPCS4.3 GrouperGrouper Coding is complexCoding is complex

Background IssuesBackground Issues

How ISO-resourced are HRGs?How ISO-resourced are HRGs?

e.g. H71 consists of 8 procedurese.g. H71 consists of 8 procedures

National tariff (£7,010)National tariff (£7,010)

Procedure ActivityMinimum

CostMaximum

cost Mean CostSt.

Deviation

H71-W371 2 7,194 10,613 8,904 2,418

H71-W372 18 5,301 13,170 8,141 2,012

H71-W373 45 6,270 14,486 10,054 2,092

H71-W382 18 10,415 15,917 12,873 1,595

H71-W383 6 10,453 15,405 13,303 2,101

H71-W392 1 12,974 12,974 12,974  

H71-W394 71 2,659 25,519 8,912 3,839

H71-W574 3 9,668 21,637 16,278 6,082

Background IssuesBackground Issues Tariff set is based on average reference Tariff set is based on average reference

cost that are over 2 years old.cost that are over 2 years old.

e.g. 2006 Reference Costs for H80 e.g. 2006 Reference Costs for H80 (Cemented Hip)(Cemented Hip)

Highest Reference CostHighest Reference Cost £15,477 £15,477 Lowest Reference CostLowest Reference Cost £ 499 £ 499TariffTariff £ 5,176 £ 5,176Implant CostsImplant Costs £ 1,299 £ 1,299

Background IssuesBackground Issues

Lack of sophistication in HRGsLack of sophistication in HRGs– 65 HRGs for musculoskeletal covered under 65 HRGs for musculoskeletal covered under

national tariffnational tariff– Only 5 HRGs for hipsOnly 5 HRGs for hips

These are:These are:H01H01 Bilateral Primary Hip ReplacementBilateral Primary Hip ReplacementH70H70 Resurfacing of HipResurfacing of HipH71H71 Revisional Procedures to HipsRevisional Procedures to HipsH80H80 Primary Hip Replacement CementedPrimary Hip Replacement CementedH81H81 Primary Hip Replacement UncementedPrimary Hip Replacement Uncemented

IssuesIssues

Key drivers may result in very Key drivers may result in very different payment outcomes:different payment outcomes:– Length of stayLength of stay– DiagnosisDiagnosis– Co-morbidityCo-morbidity– Procedure undertakenProcedure undertaken– Age of patientAge of patient– Specialist top-upSpecialist top-up

Changes to PBRChanges to PBR

Changed coding to OPCS 4.3 06/07Changed coding to OPCS 4.3 06/07 Resolving issues with Group – enable Resolving issues with Group – enable

refined coding to play into tariffrefined coding to play into tariff Moving to HRG V4Moving to HRG V4

– Doubles number of musculoskeletal HRGs – to Doubles number of musculoskeletal HRGs – to 108 Core HRGs – Subdivided by complications 108 Core HRGs – Subdivided by complications and comorbidities to form 207 HRGsand comorbidities to form 207 HRGs

– Hip HRGs 4 Core HRGs - Subdivided by Hip HRGs 4 Core HRGs - Subdivided by complications and comorbidities to form 8 complications and comorbidities to form 8 HRGsHRGs

Anticipate timetable likely to be delayedAnticipate timetable likely to be delayed

Example of CodingExample of Coding

Patient has uni-compartmental knee Patient has uni-compartmental knee replacement.replacement.

Could be coded in 2 ways:Could be coded in 2 ways:

**Method 1 coded correctly as per Coding Directive - but not Method 1 coded correctly as per Coding Directive - but not financiallyfinancially

  Method 1* Method 2

Primary Procedure W521Primary prosthetic replacement of articulation

of bone using cement NEC W521Primary prosthetic replacement of articulation of

bone using cement NEC

Secondary Procedure Z765 Lower end of femur NEC Z845 Tibiofemoral joint

Tertiary Procedure Z774 Upper end of tibia NEC    

Primary Diagnosis M179 Gonarthrosis, Unspecified M179 Gonarthrosis, Unspecified

Resultant HRG H08Joint Replacements or Revisions, Site

Unspecified H04 Primary Knee Replacement

         

Tariff 3,925   5,476  

What Do You Get Paid ForWhat Do You Get Paid For Elective Stay – Same price whether inpatient or Elective Stay – Same price whether inpatient or

daycasedaycase

9 outpatient procedures – all other procedures 9 outpatient procedures – all other procedures only at outpatient tariff (e.g. removal of k-wires in only at outpatient tariff (e.g. removal of k-wires in OP only attract income of £71)OP only attract income of £71)

New outpatient c£150New outpatient c£150

Follow-up outpatient c£75Follow-up outpatient c£75

FRP and Gait assessments outside PbR – but FRP and Gait assessments outside PbR – but clinical coding important to identify appropriatelyclinical coding important to identify appropriately

What Do You Get Paid ForWhat Do You Get Paid For Specialist top-up applied in certain circumstances e.g. (70% Specialist top-up applied in certain circumstances e.g. (70%

uplift):uplift):– X092X092 Disarticulation of hipDisarticulation of hip– W551W551 Primary prosthetic interposition arthroplasty of Primary prosthetic interposition arthroplasty of

jointjoint– W562W562 Primary interposition arthroplasty of joint necPrimary interposition arthroplasty of joint nec– W563W563 Revision of interposition arthroplasty of joint necRevision of interposition arthroplasty of joint nec

For revision arthroplasty uplifts are applied if one of the For revision arthroplasty uplifts are applied if one of the following diagnoses is identified as the primary diagnosis:following diagnoses is identified as the primary diagnosis:– M84M84 Disorders of continuity of boneDisorders of continuity of bone– M86M86 OsteomyelitisOsteomyelitis– T845T845 Infection and inflammatory reaction due to internal Infection and inflammatory reaction due to internal

joint prosthesisjoint prosthesis

Surviving the SystemSurviving the System Must not Must not gamegame

– but can improve qualitybut can improve quality– large changes discuss with Commissionerslarge changes discuss with Commissioners

Ensure coders have information needed to codeEnsure coders have information needed to code Must be timely (after national cut off dates not Must be timely (after national cut off dates not

able to re-adjust)able to re-adjust) Key to Trust understanding costsKey to Trust understanding costs

– Implant costsImplant costs– Theatre TimeTheatre Time– Ward type and length of stayWard type and length of stay

Recording accurate dataRecording accurate data

Surviving the SystemSurviving the System

Managers and Clinicians work closely Managers and Clinicians work closely together to achieve greater together to achieve greater understanding of costs – and rewards understanding of costs – and rewards earned for work undertakenearned for work undertaken

e.g. looking at implants usede.g. looking at implants used Remember PBR English only SystemRemember PBR English only System