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. 2013 Aug 6;91(10):746–756A. doi: 10.2471/BLT.12.115931

Hospital payment systems based on diagnosis-related groups: experiences in low- and middle-income countries

Systèmes de paiement des hôpitaux basés sur des groupes homogènes de diagnostic: expérience dans les pays à revenu faible et moyen

Sistemas de pago hospitalario basados en grupos relacionados por el diagnóstico: experiencias en países de ingresos bajos y medianos

أنظمة الدفع في المستشفيات على أساس المجموعات المرتبطة بالتشخيص: الخبرات في البلدان منخفضة ومتوسطة الدخل

基于诊断相关组的医院支付系统:中低收入国家的经验

Системы платежей в больницах по клинико-статистическим группам: опыт стран с низким и средним уровнем доходов

Inke Mathauer a,✉, Friedrich Wittenbecher b
PMCID: PMC3791650  PMID: 24115798

Abstract

Objective

This paper provides a comprehensive overview of hospital payment systems based on diagnosis-related groups (DRGs) in low- and middle-income countries. It also explores design and implementation issues and the related challenges countries face.

Methods

A literature research for papers on DRG-based payment systems in low- and middle-income countries was conducted in English, French and Spanish through Pubmed, the Pan American Health Organization’s Regional Library of Medicine and Google.

Findings

Twelve low- and middle-income countries have DRG-based payment systems and another 17 are in the piloting or exploratory stage. Countries have chosen from a wide range of imported and self-developed DRG models and most have adapted such models to their specific contexts. All countries have set expenditure ceilings. In general, systems were piloted before being implemented. The need to meet certain requirements in terms of coding standardization, data availability and information technology made implementation difficult. Private sector providers have not been fully integrated, but most countries have managed to delink hospital financing from public finance budgeting.

Conclusion

Although more evidence on the impact of DRG-based payment systems is needed, our findings suggest that (i) the greater portion of health-care financing should be public rather than private; (ii) it is advisable to pilot systems first and to establish expenditure ceilings; (iii) countries that import an existing variant of a DRG-based system should be mindful of the need for adaptation; and (iv) countries should promote the cooperation of providers for appropriate data generation and claims management.

Introduction

A key factor for a more rapid move towards universal health coverage is the efficient use of resources, coupled with increased resource mobilization and improved pooling. Substantial efficiency gains could be made by reforming hospital payment mechanisms,1 especially since expenditure on hospital services comprises one of the largest shares of total health-care spending in all countries, regardless of their income level.1,2

Payment systems based on diagnosis-related groups (DRGs) are one type of such hospital payment mechanisms, along with capitation payments, global budgets and a combination thereof. Although DRG-based payment systems are now mainly understood as a reimbursement mechanism, their original purpose was to enable performance comparisons across hospitals.3–5 Today DRGs are used primarily by purchasers to reimburse providers for acute inpatient care, but in principle they can also be used to reimburse them for non-acute inpatient care. By definition, DRGs classify cases according to the following variables: principal and secondary diagnoses, patient age and sex, the presence of co-morbidities and complications and the procedures performed. Cases classified as belonging to a particular DRG are characterized by a homogenous resource consumption pattern and, at the same time, DRGs are clinically meaningful. Thus, cases within the same DRG are economically and medically similar.2,3 DRG-based payment systems are often referred to as “case-based” or “case-mix-based”, yet DRG-based and case-mix-based payment systems are not the same. Even though the two overlap and are separated in practice by fluid boundaries, a DRG-based system is different in that it is based on a DRG grouping algorithm.4 In fact, the two core design characteristics of a DRG-based payment system are: (i) an exhaustive patient case classification system (i.e. the system of diagnosis-related groupings) and (ii) the payment formula, which is based on the base rate multiplied by a relative cost weight specific for each DRG.2

Since the 1990s, payments based on DRGs have gradually become the principal means of reimbursing hospitals for acute inpatient care in most high-income countries.5 The most frequent reasons for introducing DRG-based payments are to increase efficiency and contain costs.5 Street et al. have reviewed the little evidence that is available on the impact of different DRG-based payment systems in high-income countries in Europe.6 Their findings suggest that DRGs generally help to increase hospital efficiency by reducing the average length of stay but that they also increase case volumes.

Meanwhile, more and more low- and middle-income countries have begun to explore or have established DRG-based payment systems, mostly for the reimbursement of acute inpatient care. With the exception of country papers or manuals on how to introduce case-based payment and DRGs,5,7 there is no comprehensive overview of DRG practices in low- and middle-income countries. This paper addresses this gap in the literature by being the first to provide a comprehensive overview and assessment of DRG experiences in low- and middle-income countries. Its purpose is to compile country experiences and to explore the design and implementation issues that low- and middle-income countries face. Ultimately it will be a source of policy lessons for policy-makers in other low- and middle-income countries who are deliberating on whether or not – and, if so, how – to move towards a DRG-based payment system. Because the evidence is scanty and impact evaluations are few, this paper cannot review the impact of DRG-based payment systems. It can only provide illustrative examples of policy lever effects, primarily from countries that have already established a DRG-based payment system.

The following section briefly outlines the methods and core design components that we followed in assessing countries’ experiences with DRG-based payment systems. We subsequently present emerging aspects and trends in the design and implementation of these systems. These and the challenges they entail are considered in the discussion section, which is followed by a set of conclusions and policy lessons for other countries that are exploring the establishment of DRG-based payment systems.

Methods

Fig. 1 summarizes the core design components of DRGs, namely: (i) DRG variant; (ii) cost weights; (iii) expenditure ceilings and (iv) adjustment factors. The figure also outlines how values can be set for these components and their potential effect as policy levers. We will explore country experiences in terms of these design components and the respective policy levers (i.e. the possible effects of such design choices). Importantly, the qualitative and quantitative effect of a DRG-based payment system is also contingent upon the payment mechanism that is replaced.6

Fig. 1.

Fig. 1

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Core design components of diagnosis-related groups (DRGs)

Several issues are involved in the operation of a DRG-based payment system. Foremost, such a payment system creates unwanted incentives for increased hospital admissions, up-coding (i.e. the intentional and wrongful augmentation of case severity and thus reimbursement) and under-provision of necessary services.5,8 This occurs in all settings. Here, however, the focus is on implementation issues that are critical in a low- or middle-income country: (i) the piloting of such a system; (ii) problems with coding standardization, data availability and information technology requirements; (iii) integration of the private sector, and (iv) hospital autonomy.

We conducted a search of the literature published from 1980 until December 2012. We started by searching for peer-reviewed English-, French- and Spanish-language publications indexed in Pubmed and in the Pan American Health Organization’s Regional Library of Medicine (BIREME) on the subject of the design, piloting or implementation of DGR-based payment systems in low- and middle-income countries. Since we found very few sources that fulfilled our criteria, we also searched Google in the three languages to capture the grey literature (e.g. consultancy reports, government reports).

In a first step, to establish a list of countries with a DRG-based payment system, we combined the following search terms: diagnosis-related group [MeSH Terms] AND low-income country OR middle-income country OR low-income countries OR middle-income countries. In Google, the search terms also included provider payment mechanism OR case-mix OR DRG OR health system financing OR case-mix financing OR case-based funding. We also consulted health financing experts from the different regions of the World Health Organization to confirm the country list. Once we had an established list of countries, we performed a second literature search in PubMed, BIREME and Google that focused on each country. The name of each country was combined with the following search terms or phrases: DRG, diagnosis-related groups, case-mix, provider payment mechanism, health system financing and case-based funding. In this way we not only established a list of countries applying or developing a DRG-based payment system, but also – and more importantly – retrieved more information on those critical aspects of system design and implementation that we described earlier. The study selection process is outlined in Fig. 2. We used 84 documents for this country-based analysis.

Fig. 2.

Flowchart showing study selection process for systematic review of studies on payment systems based on diagnosis-related groups (DRGs) in low- and middle-income countries

a In Google, the first six pages, with 10 results per page, were considered.

b For 29 countries; also in Spanish for six Latin American countries and in French for Tunisia.

Fig. 2

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This overview focuses on low- and middle-income countries that have already established – or are in the process of developing – DRG-based payment systems. Because it also seeks to explore critical aspects of design and implementation, it also includes all those countries with established DRG-based payment systems that were in the World Bank’s middle-income country category when they adopted such systems but that have moved into the high-income category within the past 10 years.9 In this way we have tried to capture the experience of low- and middle-income countries over a full decade of development of DRG-based payment systems.

Findings

Design patterns

DRG development stage

Countries operating DRG-based payment systems vary widely in terms of gross domestic product and total health expenditure per capita, as shown in Table 1 (available at: http://www.who.int/bulletin/volumes/91/10/12-115931), which summarizes relevant health expenditure indicators. Twelve low- and middle-income countries located in all regions had established a DRG-based payment system by the end of 2012. Another 17 countries are currently piloting or exploring design options for the establishment of such a system. Of the 12 countries with an established system, only Kyrgyzstan is a low-income country; most are located in eastern Europe, and nine were under Soviet influence.

Table 1. Health expenditure indicatorsa for 2010 .
Countries Country income classificationb GDP per capita (US$) THE as percentage of GDP GGHE as percentage of general government expenditure Social security funds as percentage of GGHE GGHE as percentage of THE GGHE as percentage of THE in year when DRG-based payment system was introduced
With DRG system
Croatia HI (2008) 13 739 7.8 17.7 91.0 84.9 84.9 (2009)
Estonia HI (2006) 14 146 6.0 11.7 91.2 78.7 66.8 (2004)
Hungary HI (2007) 12 863 7.3 10.3 84.3 69.4 84.0 (1995)c
Indonesia LMI 2 946 2.6 7.8 13.9 49.1 49.1 (2010)
Kyrgyzstan LI 865 6.2 10.7 67.3 56.2 41.1 (2001)
Lithuania UMI 11 100 5.2 12.6 82.9 73.0 71.3 (2011)d
Mexico UMI 9 547 6.3 12.1 55.4 48.9 47.8 (1999)
Mongolia LMI 2 207 5.4 8.0 41.4 55.1 55.1 (2010)
Poland HI (2009) 12 292 7.5 11.9 83.7 72.6 72.3 (2009)
Romania UMI 7 673 5.6 10.8 80.7 78.1 75.1 (2004)
Thailand UMI 4 614 3.9 12.7 10.1 75.0 63.5 (2002)
The former Yugoslav Republic of Macedonia UMI 4 470 7.1 12.9 91.7 63.8 66.5 (2009)
Piloting or exploring a DRG system
Argentina UMI 9 163 8.1 14.7 59.4 54.6 –
Bulgaria UMI 6 333 6.9 9.8 64.6 54.5 –
Chile UMI 11 901 8.0 16.3 14.2 48.2 –
China UMI 4 358 5.1 12.1 64.7 53.6 –
Colombia UMI 6 223 7.6 20.1 46.4 72.7 –
Costa Rica UMI 7 419 10.9 29.0 86.2 68.1 –
Islamic Republic of Iran UMI 5 655 5.6 10.5 55.3 40.1 –
Latvia UMI 10 735 6.7 9.2 0.00 61.1 –
Malaysia UMI 8 373 4.4 9.2 0.7 55.5 –
Montenegro UMI 6 346 9.1 13.6 97.9 67.2 –
Republic of Moldova LMI 1 630 11.7 13.1 88.1 45.8 –
Serbia UMI 5 270 10.4 14.1 94.2 61.9 –
South Africa UMI 7 255 8.9 11.9 2.5 44.1 –
Tunisia UMI 3 832 6.2 10.7 48.4 54.3 –
Turkey UMI 10 060 6.7 12.8 60.1 75.2 –
Uruguay UMI 11 953 8.4 20.4 58.8 67.1 –
Viet Nam LMI 1 212 6.8 7.8 36.0 37.8 –
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DRG, diagnosis-related groups; GDP, gross domestic product; GGHE, general government expenditure on health; HI, high-income; LI = low-income; LMI, lower-middle-income; THE, total health expenditure; UMI, upper-middle-income; US$, United States dollar; WHO, World Health Organization.

a World Health Organization (WHO) national health accounts estimates.

b World Bank income classification. Figures in parentheses indicate the year when the country entered the classification shown.

c Earliest available data.

d Latest available data (introduction in 2012).

Source: Latest data available: WHO 2012 (data for 2010); World Bank 2013 (data for 2011).

Table 2 summarizes the main features of DRG system design for countries that already have nationwide DRG-based payment systems. The second group of countries – those piloting systems or exploring design options – is composed of middle-income countries, only two of which are classified as being in the lower-middle-income bracket. They, too, are situated in all regions. This group of countries may not be comprehensive, however, since other countries may also be exploring the development of a DRG-based payment system but policy documentation to this effect might not be publicly available. Table 3 provides an overview of the countries that are piloting a DRG-based payment system or exploring the establishment of such a system, and it presents some features of system design. One country – Kazakhstan – introduced a DRG-based payment system but abandoned it in 2010.80 Several other countries, such as Ghana and the Philippines, have introduced case-mix-based payments and may want to move towards DRG-based payment systems at a later stage. In fact, Ghana calls its groupings the “G-DRGs” (with the initial G standing for Ghana).81 More detailed country overviews can be found in Mathauer & Wittenbecher.82

Table 2. Context and features of institutional design aspects in countries with nationwide DRG-based payment systems.
Country Purchaser(s) paying via DRG Year when DRG-based payment piloted/introduced DRG variant (and changes) No. of case groups (and development)a Expenditure/volume ceilings Type of DRG piloting
Croatiab National social health insurance scheme10 2007: piloting11 AR-DRGs10,11 67112 Provider-specific hard budget cap11 Shadow billingc,11
2009: national implementation as payment method13
Estoniab National social health insurance scheme14,15 2003: piloting NordDRG15 2003: 498 Provider-specific soft budget cap based on cost and volume (up to 30% overruns reimbursed) Shadow billingc; incremental increase of share of hospital payment via DRGs (70% since 2009)16
2004: national implementation as payment method15 2010: 65516 Health insurance funds as a whole are capped, if funds are exhausted there are no additional transfers from the state budget14
Hungaryb National social health insurance scheme17 1987: piloting; Self-developed, based on/influenced by HCFA-DRGs18 1993: 43719 Service-type-specific hard budget cap based on volume; budget transfers between providers possible; in the past, volume contracts implied annually decreasing volumes18 In selected hospitals20
1993: national implementation as payment method19,21 mid-/end-1990s: 75819
2010: 78018
Indonesia Jamkesmas-Program for the poor: tax-financed health insurance scheme22 2009: piloting; HCFA-DRG-based23; shift to INA-DRGbased on UNU-grouper envisaged24 1077 DRGs23 NA In selected hospitals22
2010: national implementation as payment method22
Kyrgyzstan National social health insurance scheme25 1997: piloting;26 Self-developed, based on/influenced by HCFA-DRGs26 1997: 28 (56)26 Provider-specific budget cap based on cost and volume with sanctions for overruns25 Limited number of DRGs26; later in selected hospitals5
2001: national implementation as payment method;5 1999: 1405
2003: major revision and refinement, introduction of ICD-10 coding5 2005: 1505
Lithuania National social health insurance scheme27 2011: piloting;28 AR-DRG28 NA NA NA
2012: national implementation as payment method27
Mexico National social health insurance scheme (for formal sector workers)29 NA (late 1990s)29 Self-developed and based on/influenced by HCFA-DRGs30,31 2011: 70032 NA NA
Mongolia National social health insurance33 2006: piloting Self-developed34 2006: 22 Provider-specific budget cap33 Small number of DRGs35
2010: national implementation as payment method35 2010: 11535
Polandb National social health insurance36 2008: piloting British HRGs37 2008: 51837 NA Piloting in selected hospitals (6 months) then national pilot with DRGs for reporting only (6 months)37
2009: national implementation as payment method37 2012: 51938
Romania National social health insurance39 1999: piloting Until 2007: HCFA-DRG Until 2007: 499 DRGs Hard budget cap for hospital sector; additionally provider-specific hard budget cap based on volume; budget transfers between providers possible40 Piloting in selected hospitals, number of pilot hospitals incrementally increased from 1 to 23 between 1999 and 200239
2004: national implementation as payment method39 Since 2007: AR-DRG (ICD-10-based)40 Since 2007: 665 DRGs40
2005–2010: extension of the system to different hospital types (Ministry of Defence and private hospitals excluded)40
Thailand i) UCS: tax-financed social health insurance i) UCS: 2001: piloting HFCA-/AR DRG-based, later Thai versions 2011: 2 450 (ICD-10-based), plus 54 TMHCC and 41 sub-acute/ non-acute patients)41 i) UCS: hard budget cap i) UCS: piloting in hospitals of 10 provinces and for 100 accident DRGs42
ii) CSMBS: contribution-based social health insurance42,43 2002: national implementation as payment method ii) CSMBS: no budget cap42 ii) CSMBS: different base rate for each hospital41
2003, 2007, 2010, 2011: refinements
ii) CSMBS: 2007: national implementation as payment method41,44
The former Yugoslav Republic of Macedonia National social health insurance scheme45 2009: national implementation, basis for hospital budgets46 AR-DRG47 66648 NA Shadow billingc,45
2010: extension to psychiatric and private hospitals48
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AR-DRG, Australian refined DRG; CSMBS, Civil Servant Medical Benefit Scheme; DRG, diagnosis-related group; HCFA-DRG, Health Care Financing Administration DRG; HRG, Health Care Resource Group; ICD-10, International Classification of Diseases, tenth revision; INA-DRG, Indonesia DRG; NA, not available; TMHCC, Thai mental health case mix classification; UCS, Universal Coverage Scheme; UNU, United Nations University.

a Croatia, Estonia, Hungary and Poland were middle-income countries when the DRG-based system was developed and introduced but moved to the high-income country group in 2008, 2006, 2007 and 2009, respectively.

b Year given if known and/or if a change of number of groups has taken place.

c Shadow billing: DRGs used for reporting and (mock) billing, though actual reimbursement is still according to the previous payment system.

Table 3. Countries piloting or exploring a hospital payment system based on diagnosis-related groups (DRGs).
Country Design and implementation
Argentina49 DRGs used by some hospitals for reporting and analysis
Bulgaria50,51 Introduction of a DRG-based payment system under discussion
Chile52,53 Research trials started in early 2000s for reporting in selected hospitals based on AP-DRGs; more recent trials under ministerial guidance favour IR-DRGs
China54,55 AR-DRGs trialled in selected hospitals for recording and in others for shadow billing;a also case classification development
Colombia56–59 DRGs used by some hospitals for reporting and monitoring since mid-2000s
Costa Rica60 DRGs used for reporting nationally since1998; 999 DRGs based on HCFA-DRG updated with ICD 10
Islamic Republic of Iran61–64 Research trials mapping inpatient cases of selected hospitals with AR-DRGs
Latvia65 Introduction of a DRG-based payment system based on NordDRGs envisaged for 2014b
Malaysia66,67 DRG-based payment system based on UNU-grouper is under discussion; trials already conducted in selected hospitals
Montenegro68 Introduction of a DRG-based payment system under discussion
Republic of Moldova69,70 Introduction of a DRG-based payment system under discussion; unlimited AR-DRG license purchased 2012
Serbia71 Introduction of a DRG-based payment system based on AR-DRGs planned; ongoing trials in selected hospitals
South Africa72 DRGs used by some hospitals and managed care companies for own analysis; introduction of a DRG-based payment system under discussion
Tunisia73 Implementation of a DRG-based payment system based on GHM (the French DRG variant) in selected hospitals for a limited set of diagnoses in 2007
Turkey74,75 Introduction of a DRG-based payment system based on AR-DRGs decided upon after a research and trial period (2005–2009); currently hospitals receive global budgets and 10% of hospital budgets are allocated according to DRG-derived case mix since 2011; incremental increase plannedc
Uruguay76,77 Research trial of IR-DRGs in one hospital; further research on feasibility of a DRG-system based on UNU-grouper
Viet Nam78,79 Research trial of 4 DRGs in selected hospitals; ongoing data collection for development of a UNU-grouper based DRG-system
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AP-DRG, all patients DRG; AR-DRG, Australian refined DRG; GHM, Groupes Homogènes des Malades; HCFA-DRG, Health Care Financing Administration DRG; ICD-10, International Classification of Diseases and Related Health Problems 10th Revision; IR-DRG, international refined DRG; UNU, United Nations University.

a Shadow billing: DRGs used for reporting and (mock) billing, though actual reimbursement is still according to the previous payment system.

b U Mitenberg & E Mikits, personal communication.

c U Basara, personal communication.

Rationale for DRG introduction

As is the case in many high-income countries, DRG-based payment systems were usually introduced in the countries described in this paper to contain costs, to increase efficiency in inpatient care or to improve transparency in hospital activities. Of these, increasing efficiency is the reason most closely linked to DRG-based payment systems and the rationale behind the introduction of such systems in former Soviet republics still grappling with a legacy of overcapacity in inpatient care, such as Estonia14 and Kyrgyzstan.26,83 China,84 Hungary19, The former Yugoslav Republic of Macedonia,85 Romania39 and Serbia71 also expect DRG-based payment systems to increase efficiency. Making hospital activity more transparent for purchasers and providers was an explicit objective in Poland37 and Serbia.71 In China84 and The former Yugoslav Republic of Macedonia,86 the introduction of DRG-based payment systems is also expected to improve service quality. In Croatia, DRG-based payment is used to increase the number of cases seen and reduce waiting lists.13 As discussed in the following section, these specific objectives are, in principle, decisive when it comes to choosing a particular design for a DRG-based payment system.

DRG variants chosen

Most low- and middle-income countries use DRG-based payments as a retrospective payment mechanism; only The former Yugoslav Republic of Macedonia uses DRGs as a basis for prospective budgeting decisions. The DRG variant chosen by a country determines the number of case groups as well as the cost weights or range of cost weights used, yet country-specific adjustments, to be discussed in a subsequent section, may be required. As shown in Table 2, the DRG variants chosen by the countries cover the full range of existing DRG variants. Moreover, some countries switched from one variant to another or developed their DRG-based systems over time by making adjustments, such as generating more detailed and specific case groupings. This dynamic developmental process of introducing and implementing DRGs appears to reflect improvements in administrative and operational capacity, i.e. in the capacity of countries to run an increasingly sophisticated DRG-based payment system.

Most of the low- and middle-income countries in this study use a DRG-based hospital payment system consisting of about 500 to 800 case groups. Kyrgyzstan and Mongolia are exceptional in having a much lower number of case groups. In Kyrgyzstan case groups are broader and the classification system is less demanding, since the DRG-based payment system serves to provide hospitals with funding in addition to budget allocations.5 In Mongolia, the health ministry directly finances many inpatient services,33 which results in fewer remaining DRGs. On the other hand, Indonesia and Thailand have 1077 and 2700 case groups, respectively. A higher number of groups may reflect a more sophisticated health-care system that provides a greater variety of services. On the other hand, fewer groups could also signify that the groupings are deliberately broader, which increases the need for efficient use of resources on the provider side.

Finally, only Kyrgyzstan26 was found to apply adjustment factors to calibrate its payment system for different provider levels and for different regions. In addition, the country trialled a higher base rate at the regional level for patients who were exempted from formal co-payments.26

Ceilings

The base rate value is ultimately a reflection of the overall amount of funding available. Thus, establishing an explicit budget and setting volume ceilings are equally important in guiding hospital management. All countries for which information is available do indeed have a ceiling in place. The purpose of volume or budget ceilings as a policy lever is to contain costs, but their effects can vary. In Hungary, for example, the negotiated volume levels decreased over the years and, as a result, waiting periods increased.18 In Mongolia, hospital volume ceilings have created an incentive to exhaust the maximum volume set.33 This might easily lead to unnecessary admissions. Flexible case volume allocations across hospitals depending on utilization rates within a global ceiling, such as in Romania,39 are another possibility. Yet, the incentive for a hospital to increase its case volume remains. In Thailand, on the other hand, the base rate varies in accordance with the overall number of cases to stay within the total budget.87

Adaptation

The final step upon choosing a DRG-variant is the process of adapting it to a specific country context. This applies primarily to cost weights but also to case grouping in the case of an imported system. Adaptation is needed because the cost structure of delivering acute care may vary considerably across countries, depending on their level of technology and the degree of labour applied. If cost weights are inadequately adjusted, it may create the wrong incentives. Most countries have in fact undertaken some adjustment of cost weights to their country context. For example, Kyrgyzstan26 and Poland37 used the costing data that were available before the introduction of the DRG-based system for their case weight adjustment. In Croatia, costing studies were conducted for this purpose,11 whereas The former Yugoslav Republic of Macedonia took the cost weights from Croatia47 and adjusted them to its own context. In contrast, in Romania cost weights were not adjusted in accordance with the clinical reality and this created the incentive to up-code in various medical specialties.40

Implementation issues

Piloting

To pilot a DRG-based payment system, a country can begin with any of the following paths or a combination thereof: (i) a limited number of hospitals; (ii) a subset of hospital cases paid by DRGs; (iii) a subset of costs; (iv) shadow billing (i.e. DRG claims are sent in and a mock bill is provided to inform the hospital of its potential remuneration amount); or (v) a hospital-specific base rate is gradually converted to a nationwide rate. We found that, like most high-income countries belonging to the Organisation for Economic Co-operation and Development, all countries piloted DRGs before implementing a DRG-based payment system nationwide (Table 2).8 The piloting and extension period usually spread over several years. Most countries chose a combination of piloting paths, but the most frequent one was the first option mentioned here – a limited number of hospitals. The last option – a hospital-specific base rate that was gradually converted to a nationwide rate – was not followed by any country. In some of the countries in the exploratory stage, DRGs have been used so far for case classification only, but not for payment, particularly in Latin America (Table 3).

Capacity needed to start the DRG system

If specific information technology requirements and a data generation system for case payments are already in place before a DRG-based system is introduced, as was the case in The former Yugoslav Republic of Macedonia, the shift to DRGs will be much easier.47 However, during the introduction and piloting phases especially, generating clinical and costing data and linking them via an appropriate information technology system can prove difficult. This difficulty is inherent in that the availability of data on diagnosis is a prerequisite for DRG-based payments, but the systems needed to generate the necessary data are not usually set up until a DRG-based system is already in place. For example, in an Estonian Health Insurance Fund publication it was noted that providers were only motivated to apply the coding scheme once DRGs were in place as a payment system.15 An interesting way of enhancing provider cooperation was used in Kyrgyzstan, where the introduction of DRGs was accompanied by performance-based staff bonuses that improved providers’ acceptance of the system.26

In other countries, a lack of standardized and systematized data generation and coding has been slowing down the introduction of DRGs. In the Viet Nam pilot, for example, the relevant input data were recorded at the hospital level but scattered among different work stations within the hospitals and were thus not fully ready to be used in a DRG-based payment system.78 When new coding methods and data generation tools are introduced, extensive training of medical staff becomes necessary, as specifically reported in Estonia15, the Islamic Republic of Iran,61 Serbia71 and Viet Nam.78 In Thailand, for instance, it was recommended to train coders after reports that a high proportion of DRGs were being wrongly assigned.43 This example underscores the need for auditing of DRG-based payment systems to detect errors in coding practices. Incorrect coding practices can be overcome with training, but fraudulent coding practices also occur and call for regular coding practice audits. Thus, piloting should also be viewed as a way to eventually develop the necessary capacity.

Integration of private sector providers

In many countries, DRG-based payments apply to both public and private sector providers. In fact, the shift from budget allocations to DRG-based payment systems makes the inclusion of the private sector in the provision of services – i.e. publicly financed services – more appealing. Yet, when a purchaser offers different reimbursement for private sector services, the implications are many. For one thing, the expected efficiency gains of a DRG-based payment system are then limited to the public sector. In addition, there is no fair competition between public and private providers. For example, in Romania,40 DRG-based payments apply only to public providers, whereas private providers are paid on a negotiated fee for services.

When calculating DRG tariffs for private providers, the fact that these do not receive supply-side financing from the government should be borne in mind. In Mongolia, however, the DRG base rate for private providers was only 50% the rate applied to the public sector, with balance billing permitted at the providers' own discretion.33 Regulating – and prohibiting – balance billing is thus important for protecting patients from excessive user charges but may create incentives for providers to charge informal payments if DRG rates are below costs.

Hospital autonomy

To respond to incentives to improve efficiency – i.e. streamline the use of resources and shift resources to their most effective use – hospitals need a certain degree of autonomy in management and spending. Essentially, it is important to delink hospital financing from public finance administration, and most countries have done so. For example, in Poland the legal status of all hospitals was changed to that of independent institutions in the course of health system reforms.37 Similarly, in Estonia all hospitals have been operating independently under private law since 2001.16 In contrast, Mongolian hospitals continue to run and report with a line-itemized budget logic and have limited autonomy,33 and Kyrgyzstan is reportedly struggling in its efforts to delink hospital financing from public finance.88

Discussion

Countries can choose between pre-existing DRG system variants (“importing” such systems) and developing their own. Adapting an imported DRG variant might imply sacrificing coherence in design, whereas self-developed systems can start out as a simpler alternative. However, these two options are divided by a very fine line and are really the extremes of a continuous scale, since major adaptations are required when an existing DRG variant is imported. In general, however, a country will probably need to invest more resources if it chooses to develop its own system. For example, Estonia15 and Lithuania,28 two small countries, decided not to develop their own DRG classification systems because it was considered too resource-intensive. On the other hand, larger countries, such as Indonesia24 and Thailand,41 implemented self-developed DRG-based systems for the most part and China54,55 also seems to be leaning towards a self-developed system.

The choice of a specific DRG variant depends on many factors. They have to do with the specific country context, the influence of external funding agencies, the degree of regional cooperation and exchange with neighbouring countries, and the time when the system is introduced. For example, the Scandinavian NordDRGs are found in Estonia and Latvia, whereas AR-DRGs (AR for “Australian Refined”) were introduced in Slovenia89 and later applied or explored in other countries of south-eastern Europe, such as The former Yugoslav Republic of Macedonia47 and Romania.40 Countries that began developing DRGs in the early 1990s, such as Kyrgyzstan and Hungary, were probably influenced by the American HCFA-DRG system because this was the one most readily accessible at the time.

There seems to be an important role for governments. In every country, once the types of hospitals to which the DRG-based payment system would apply had been decided, the use of DRGs for remuneration was made mandatory. Similarly, all DRG-based payment systems, whether established or under pilot testing, are operated by public health insurance schemes, with Latin America being somewhat unique in that the hospitals contributed to fostering DRG development. Moreover, government health expenditure plays a crucial role as well. At the time when DRG-based systems were implemented, government health expenditure was about two thirds of total health expenditure in all countries except Indonesia, Kyrgyzstan and Mexico. In contrast, in countries piloting or exploring the possibility of establishing DRG-based systems of payment, government expenditure on health is usually less than 66% of total health expenditure; it is more than this share in only 6 of the 17 countries. This suggests that an established health financing system based on pooling and prepayment is necessary for the launching of such payment reforms.

Many of the schemes seem to be constrained by tight funding. DRG-based tariffs and payments are often perceived or reported as being too low. This is the case in Kyrgyzstan,88 The former Yugoslav Republic of Macedonia (Lazarevik personal communication, 2011), Mongolia33 and Romania.40 Tight funding – or underfunding – make it very difficult to implement DRGs because providers are less likely to cooperate. Thus, it is critically important to collect cost data to ensure adequate reimbursement, facilitate acceptance of a DRG-based payment system, and encourage provider cooperation.

Several countries, such as Hungary, Indonesia, Mongolia and Thailand, have multiple health insurance schemes, in addition to government budget allocations to providers. The existence of fragmented purchasing arrangements with different, often non-aligned, provider payment systems is not a problem specific to DRG-based hospital systems. However, it does also become a concern in the context of a DRG-based payment system when there are conflicting incentives at the hospital level. For example, budget allocations may be based on the number of beds and staff members, whereas DRG-based systems incentivize fewer inputs per case. Or hospitals can find the remuneration schemes and rates of one purchaser more attractive financially than those of another. The Thai civil servant medical benefits scheme offers an example. In contrast to the Thai Universal Coverage Scheme, it receives higher DRG-based tariffs to which no budget ceiling applies.42 Similarly, the Indonesian insurance scheme for formal sector employees remunerates providers of inpatient care on a fee-for-service basis,22 a payment method frequently preferred by providers. Hence, the most important thing is for purchasing mechanisms to be aligned with each other. Finally, extensive pooling and a large financial or case volume for DRG-based payments may be preferable. Yet the example from Kyrgyzstan has shown that even if a small share of the costs is reimbursed via DRGs (but with a high case volume), substantial impact can result from the way the DRG payment system is designed.5

Although the challenges are many, initial signs of success are emerging. According to Health Insurance Fund sources, in The former Yugoslav Republic of Macedonia the DRG-based payment system has resulted in a decrease in the number of hospital beds and in the average length of inpatient stay and is widely accepted by providers.48 In Kyrgyzstan, capacity for inpatient care was considerably reduced.5 The introduction of a DRG-based system in Croatia also reduced the average length of stay but had little impact on volume and no adverse effect on quality.12 Moreno-Serra and Wagstaff90 have assessed the shift from input-based budgeting to case-based payment methods in several countries of eastern and central Europe and central Asia. Although they assessed all case-based payment systems and not just those based on DRGs, overall they found a decrease in average length of stay and no increase in hospital admissions, but there was an increase in inpatient expenditure per case.

Study limitations

A major limitation of our study lies in the nature of much of the data used. Some were obtained from the non-peer-reviewed and grey literature or through a Google search. The Google search is not fully replicable because search results can change very quickly. Hence, our study is more of an overview than a systematic review. Moreover, the language restrictions we imposed may have also resulted in the omission of country publications in other languages.

Conclusion

This overview shows that low- and middle-income countries in all parts of the world are using DRG-based payment systems to remunerate health-care providers. Overall, a DRG-based payment system is administratively and technically complex and its effective operation hinges on various institutional and organizational conditions.8 Nonetheless, the introduction of a DRG-based payment system should be seen as a dynamic developmental process during which these conditions can be met incrementally. Research stemming from specific countries is needed to further explore the potential effect of various aspects of DRG-based systems design and policy levers.

Our findings suggest that, if a country decides to introduce a DRG-based payment system, health financing should come primarily from public rather than private sources.5 Piloting the system, particularly through selected hospitals and in combination with shadow billing and/or selected DRG groups, is advisable. If an existing DRG variant is imported, careful attention should be given to adjusting it to the local context. Eventually DRGs should be applied to as many different inpatient care providers as possible to avoid creating undesirable incentives. Finally, provider cooperation needs to be promoted to enhance appropriate data generation and claims management. Additionally, some form of expenditure or volume ceiling would help to incentivize the efficient use of resources.

Ultimately, the introduction of a DRG-based system is part of a long path of continuous development and adjustment of provider payments. It might involve combining different provider payment mechanisms to arrive at the optimal mix of incentives, as has been done in many advanced health financing systems.

Acknowledgements

We are very grateful to Tamas Evetovits, Joe Kutzin, Luisa Pettigrew and Wilm Quentin for comments and feedback. We also gratefully acknowledge helpful information from Syed Aljunid, Gabriel Bastias, Erdenechimeg Enkhee, Jarno Habicht, Vladimir Lazarevik, Eriks Mikiti, Uldis Mitenbergs, Walaiporn Patcharanarumol, Julio Suarez and Szabolcs Szigeti.

Competing interests:

None declared.

References

  • 1.The world health report: health systems financing: the path to universal coverage Geneva: World Health Organization; 2010. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Cylus J, Irwin R. The challenges of hospital payment systems. EuroObserver. 2010;12:1–12. [Google Scholar]
  • 3.Park M, Braun T, Carrin G, Evans DB. Provider payments and cost-containment lessons from OECD countries Geneva: World Health Organization; 2007. [Google Scholar]
  • 4.Kobel C, Thuilliez J, Bellanger M, Pfeiffer K-P. DRG systems and similar patient classification systems in Europe. In: Busse R, Geissler A, Quentin W, Wiley M, editors. Diagnosis-related groups in Europe: moving towards transparency, efficiency and quality in hospitals. Maidenhead: Open University Press; 2011. p. 37–58. [Google Scholar]
  • 5.Langenbrunner JC, Cashin C, O’Dougherty S, editors. Designing and implementing provider payment systems: how to manuals Washington: The World Bank; 2009. [Google Scholar]
  • 6.Street A, O’Reilly J, Ward P, Mason A. DRG-based hospital payment and efficiency: theory, evidence, and challenges. In: Busse R, Geissler A, Quentin W, Wiley M, editors. Diagnosis-related groups in Europe: moving towards transparency, efficiency and quality in hospitals. Maidenhead: Open University Press; 2011. pp. 93–114. [Google Scholar]
  • 7.Cashin C, O'Dougherty S, Samyshkin Y, Katsaga A, Ibraimova A, Kutanov Y et al. Case-based hospital systems: a step-by-step guide for design and implementation in low- and middle-income countries. Geneva: Joint United Nations Programme for HIV/AIDS; 2005.
  • 8.Busse R, Geissler A, Quentin W, Wiley M, editors. Diagnosis-related groups in Europe: moving towards transparency, efficiency and quality in hospitals. Maidenhead: Open University Press; 2011. [DOI] [PubMed] [Google Scholar]
  • 9.The World Bank [Internet]. How we classify countries. Washington: WB; 2013. Available from: http://data.worldbank.org/about/country-classifications/a-short-history [accessed 28 June 2013].
  • 10.Voncina L, Merkur S, Jemiai N, Golna C, Maeda A, Chao S et al. Health systems in transition – Croatia: health system review. Copenhagen: WHO Regional Office for Europe; 2006. [Google Scholar]
  • 11.Strizrep T, Voncina L. The introduction of DRGs in Croatia. Hospital. 2009;3:36. [Google Scholar]
  • 12.Bogut M, Voncina L, Yeh E. Impact of hospital provider payment reforms in Croatia. Washington: The World Bank; 2012. [Google Scholar]
  • 13.Vončina L, Strizrep T, Bagat M, Pezelj-Duliba D, Pavić N, Polašek O. Croatian 2008–2010 health insurance reform: hard choices toward financial sustainability and efficiency. Croat Med J. 2012;53:66–76. doi: 10.3325/cmj.2012.53.66. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Koppel A, Kahur K, Habicht J, Saar P, Habicht T, van Ginneken E. Health systems in transition: Estonia – health system review Copenhagen: WHO Regional Office for Europe; 2008. [Google Scholar]
  • 15.Overview of Estonian experiences with DRG system Tallinn: Estonian Health Insurance Fund; 2009. [Google Scholar]
  • 16.Kahur K, Allik T, Aaviksoo A, Laarmann H, Paat G. Estonia: developing NordDRGs within social health insurance. In: Busse R, Geissler A, Quentin W, Wiley M, editors. Diagnosis-related groups in Europe: moving towards transparency, efficiency and quality in hospitals. Maidenhead: Open University Press; 2011. pp. 301–20. [Google Scholar]
  • 17.Gaal P, Szigeti S, Csere M, Gaál P, Szigeti S, Csere M et al. Health systems in transition – Hungary: health system review. Copenhagen: WHO Regional Office for Europe; 2011. [PubMed] [Google Scholar]
  • 18.Evetovits T. Paying hospitals by DRGs: case-study from Hungary Bangkok: Joint Learning Network; 2010. Available from: http://www.jointlearningnetwork.org/sites/jlnstage.affinitybridge.com/files/DRG_Hungary_Evetovits.pdf [accessed 28 June 2013]. [Google Scholar]
  • 19.Maylath E. DRGs in der psychiatrischen Krankenhausfinanzierung am Beispiel Ungarns. Ein Modell für Deutschland? [DRGs in psychiatric hospital financing exemplified by Hungary. A model for Germany?]. Gesundheitswesen. 2000;62:633–45. doi: 10.1055/s-2000-10429. German. [DOI] [PubMed] [Google Scholar]
  • 20.Kroneman M, Nagy J. Introducing DRG-based financing in Hungary: a study into the relationship between supply of hospital beds and use of these beds under changing institutional circumstances. Health Policy. 2001;55:19–36. doi: 10.1016/S0168-8510(00)00118-4. [DOI] [PubMed] [Google Scholar]
  • 21.Gaal P, Stefka N, Nagy J. Cost accounting methodologies in price setting of acute inpatient services in Hungary. Health Care Manag Sci. 2006;9:243–50. doi: 10.1007/s10729-006-9091-3. [DOI] [PubMed] [Google Scholar]
  • 22.Joint Learning Network for Universal Health Coverage [Internet]. Moving toward universal coverage – Indonesia. In: Joint Learning Workshop: Moving Toward Universal Health Coverage, Gurgaon, India, 3–5 February 2010. Washington: JLNUHC; 2013. Available from: http://www.jointlearningnetwork.org/content/moving-toward-universal-health-coverage [accessed 28 June 2013].
  • 23.Parede D. Implementation of INA-DRG reimbursement rates for hospitals in Jamkesmas Jakarta: P2JK Kemenkes; 2012.
  • 24.United Nations University [Internet]. 5th casemix workshop on the development of INA-CBG and roundtable discussion with stakeholders on hospital tariff. Kuala Lumpur: International Institute for Global Health; 2012. Available from: http://iigh.unu.edu/?q=node/133 [accessed 28 June 2013].
  • 25.Ibraimova A, Manzhieva E, Rechel B. Health systems in transition – Kyrgyzstan: health system review 2011 Copenhagen: WHO Regional Office for Europe; 2011. [PubMed] [Google Scholar]
  • 26.Kutzin J, Ibraimova A, Kadyrova N, Isabekova G, Samyshkin Y, Kataganova Z. Manas Health Policy Analysis Project: innovations in resource allocation, pooling and purchasing in the Kyrgyz health system Bishkek: World Health Organization & Ministry of Health; 2002. [Google Scholar]
  • 27.Jankauskienė D, Medaiskis T. Annual national report 2012: pensions, health care and long-term care Lithuania Vilnius: European Commission DG Employment, Social Affairs and Inclusion; 2012. [Google Scholar]
  • 28.Kacevicius G. DRGs in Lithuania: why DRGs and how to choose from available options Sofia: National Hospital Insurance Fund; 2011. [Google Scholar]
  • 29.Docteur E, Oxley H. Health care systems: lessons from the reform experience Paris: Organisation for Economic Co-operation and Development; 2003. [Google Scholar]
  • 30.OECD reviews of health systems: Mexico Paris: Organisation for Economic Co-operation and Development; 2005. [Google Scholar]
  • 31.Proceso de seguimineto a los aspectos susceptibles de mejora derivados de la evaluación externa del programa IMSS Oportunidades 2007 [Follow-up process of sensitive improvements aspects derived from the external evaluation of the IMSS program “Opportunities” 2007]. Mexico City: Instituto Mexicano del Seguro Social; 2008. Spanish. [Google Scholar]
  • 32.Instituto Mexicano del Seguro Social. Grupos relacionados con el diagnóstico [Diagnosis-related groups]. Mexico City: IMSS; Spanish. Available from: http://www.imss.gob.mx/profesionales/Documents/GRD_IMSS.pdf [accessed 28 June 2013].
  • 33.Dashzeveg C, Mathauer I, Enkhee E, Dorjsuren B, Tsilaajav T, Batbayar C. OASIS Mongolia – the role of institutional design and organizational practice for health financing performance in Mongolia Geneva: World Health Organization; 2011. [Google Scholar]
  • 34.Tsilaajav T, Ser-Od E, Baasai B, Byambaa G, Shagdarsuren O et al. Health systems in transition: Mongolia - health systems review Geneva: World Health Organization; 2013. [Google Scholar]
  • 35.Tungalag K, Boltman J. Review of the Mongolian health insurance system. Ulaanbaatar: Ministry of Health Mongolia; 2010. [Google Scholar]
  • 36.Kuszewski K, Gericke C, Busse R. Health care systems in transition – Poland Copenhagen: WHO Regional Office for Europe; 2005. [Google Scholar]
  • 37.Czach K, Klonowska K, Swiderek M, Wiktorza K. Poland: the Jednorodne Grupy Pacjentów – Polish experiences with DRGs. In: Busse R, Geissler A, Quentin W, Wiley M, editors. Diagnosis-related groups in Europe: moving towards transparency, efficiency and quality in hospitals. Maidenhead: Open University Press; 2011. pp. 359–380. [Google Scholar]
  • 38.Iltchev P, Sierocka A, Marczak M. The use of DRG in hospital management. Stud Logic Gramm Rhet. 2012;42:129–42. [Google Scholar]
  • 39.Vladescu C, Scintee G, Olsavsky V Health systems in transition: Romania: health system review Copenhagen: World Health Organization; 2008. [PubMed] [Google Scholar]
  • 40.Radu CP, Chiriac DN, Vladescu C. Changing patient classification system for hospital reimbursement in Romania. Croat Med J. 2010;51:250–8. doi: 10.3325/cmj.2010.51.250. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.Pannarunothai S. DRG in Thailand: development up to the Thai Casemix Version 5 Bangkok: Joint Learning Network in Universal Health Coverage; 2010. [Google Scholar]
  • 42.Tangcharoensathien V, Patcharanarumol W, Vasavid C Prakongsai P, Jongudomsuk P, Srithamrongswat S, et al. Thailand health financing review 2010 Bangkok: Thai Working Group on Observatory of Health Systems and Policy; 2010. Available from: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1623260 [accessed 28 June 2013].
  • 43.Pongpirul K, Walker DG, Winch PJ, Robinson C. A qualitative study of DRG coding practice in hospitals under the Thai universal coverage scheme. BMC Health Serv Res. 2011;11:71. doi: 10.1186/1472-6963-11-71. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Pongpirul K, Walker DG, Rahman H, Robinson C. DRG coding practice: a nationwide hospital survey in Thailand. BMC Health Serv Res. 2011;11:290. doi: 10.1186/1472-6963-11-290. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Lazarevik V, Kasapinov B, Gudeva-Nikovska D. Health system reforms in the Republic of Macedonia (1991-2010). In: NISPAcee [Internet]. 18th NISPAcee Annual Conference, Warsaw, Poland, 12–14 May 2010 Bratislava: NISPAcee; 2010. [Google Scholar]
  • 46.Apostolska Z, Gulija M. Annual national report 2012: pensions, health care and long-term care former Yugoslav Republic of Macedonia Skopje: European Commission DG Employment, Social Affairs and Inclusion; 2012. [Google Scholar]
  • 47.Karol Consulting. Macedonian DRG manual – draft for discussion Skopje: Ministry of Health; 2008. Available from: http://www.moh-hsmp.gov.mk/fileadmin/user_upload/komponenta2/MACEDONIAN%20DRG%20MANUAL.pdf [accessed 28 June 2013]. [Google Scholar]
  • 48.Lukanovska T, Dimkovski V. Annual report for 2010 Skopje: Health Insurance Fund Macedonia; 2011. [Google Scholar]
  • 49.Hospital de Pediatría S.A.M.I.C “Prof. Dr. Juan P. Garrahan” [Internet]. Indicadores [Indicators]. Buenos Aires: HPSAMIC; 2013. Spanish. Available from: http://www.garrahan.gov.ar/index.php/hospital/indicadores-de-produccion [accessed 28 June 2013].
  • 50.Georgieva L, Salchev P, Dimitrova S, Dimova A, Avdeeva O. Health systems in transition – Bulgaria: health system review Copenhagen: WHO Regional Office for Europe; 2007. [Google Scholar]
  • 51.Changing the payment system for hospital care in Bulgaria to improve equity and efficiency. Copenhagen: WHO Regional Office for Europe; 2011. [Google Scholar]
  • 52.Hospital del Salvador [Internet]. Sistema Grupos Relacionados al Diagnóstico (GRD) [Diagnosis Related Groups (DRG) system]. Santiago: HS; 2012. Spanish. Available from: http://www.hsalvador.cl/unidad-de-analisis-clinico/ [accessed 10 July 2013].
  • 53.Villalon E. Indicadores globales de producción y eficiencia clínica: grupos relacionados al diagnóstico (GRD) [Global indicators of clinical production and efficiency: diagnosis-related groups (DRGs)]. Santiago: Hospital del Salvador; 2011. Spanish.
  • 54.Zhao Y. Health care payment reform in China. In: EuroDRG [Internet]. EuroDRG Final Conference, Berlin, Germany, 17 November 2011 Berlin: Berlin University of Technology; 2011. Available from: http://www.eurodrg.eu/ [accessed 28 June 2013]. [Google Scholar]
  • 55.Boynton X, Ma O, Schmalzbach M. Key issues in China’s health care reform – payment system reform and health technology assessment Washington: Center for Strategic and International Studies; 2012. [Google Scholar]
  • 56.Arcila L. Grupos relacionados de diagnóstico y sistemas de costos en la gestión hospitalaria. In: III Congreso Latinoamericano de Adminstradores de Salud, I Congreso Peruano de Administración Hospitalaria, Lima, Peru, 13–16 November2007 [Internet]. 2007. Spanish. Available from: http://www.fepas.org.pe/congreso/ [accessed 28 June 2013]. [Google Scholar]
  • 57.Cortes A. Grupo relacionado de diagnóstico: categoría diagnóstica mayor no. 05 – estudio de caso de una aseguradora de salud en Colombia. In: 1er Congreso Internacional de Sistemas de Salud: hacia un nuevo sistema de salud en Colombia, Bogotá, Colombia, 24–26 noviembre 2010 [Internet]. Bogotá: Pontificia Universidad Javeriana; 2010. Spanish. [Google Scholar]
  • 58.Duque M, Gomez L, Osorio J.Análisis de los sistemas de costos utilizados en las entidades del sector salud en Colombia y su utilidad para la toma de decisiones. [Analysis of cost systems used in facilities of the health sector of Columbia and its usefulness for decision-taking]. Rev Instituto Internacional Custos 20095495–525.Spanish [Google Scholar]
  • 59.Castro H. Diagnosis related groups (DRGs): resourceful tools for financial crisis? Rev Ciencias Salud. 2011;9:73–82. [Google Scholar]
  • 60.Moya de Madrigal L.Aplicación de los grupos de diagnósticos relacionados a la gestión del sistema nacional de servicios de hospitalización de la CCSS. Rev Cienc Adm Financ Segur Soc 199862Spanish [Google Scholar]
  • 61.Ghaffari S, Doran C, Wilson A, Aisbett C. Trialling diagnosis-related groups classification in the Iranian health system: a case study examining the feasibility of introducing casemix. East Mediterr Health J. 2010;16:460–6. [PubMed] [Google Scholar]
  • 62.Ghaffari S, Doran C, Wilson A, Aisbett C, Jackson T. Investigating DRG cost weights for hospitals in middle income countries. Int J Health Plann Manage. 2009;24:251–64. doi: 10.1002/hpm.948. [DOI] [PubMed] [Google Scholar]
  • 63.Ghaffari S, Doran CM, Wilson A. Casemix in the Islamic Republic of Iran: current knowledge and attitudes of health care staff. East Mediterr Health J. 2008;14:931–40. [PubMed] [Google Scholar]
  • 64.Ghaffari S, Jackson TJ, Doran CM, Wilson A, Aisbett C. Describing Iranian hospital activity using Australian Refined DRGs: a case study of the Iranian Social Security Organisation. Health Policy. 2008;87:63–71. doi: 10.1016/j.healthpol.2007.09.014. [DOI] [PubMed] [Google Scholar]
  • 65.Mitenbergs U, Taube M, Misins J, Mikitis E, Martinsons A, Rurane A et al. Health systems in transition – Latvia: health system review Copenhagen: WHO Regional Office for Europe; 2008. [PubMed] [Google Scholar]
  • 66.Aljunid S, Moshiri H, Amin R. The impact of introducing case mix on the efficiency of teaching hospitals in Malaysia. In: PCSI Working Conference, Munich, Germany, 2010 15–18 September [Internet]. Munich: Patient Classification Systems International; 2013. Available from: http://pcsinternational.org [accessed 28 June 2013]. [Google Scholar]
  • 67.Moving beyond the casemix frontier: towards sub-acute and non-acute classification. In: 6th International Casemix Conference 2012 (6ICMC2012), Kuala Lumpur, Malaysia, 2012 6–7 June [Internet]. Kuala Lumpur: 6ICMC; 2013. Available from: http://iigh.unu.edu/sites/default/files/Poster%202012%20(1).pdf [accessed 28 June 2013]. [DOI] [PMC free article] [PubMed]
  • 68.Master plan: development of Montenegro for the period of 2010–2013 Podgorica: Ministry of Health Montenegro; 2010. [Google Scholar]
  • 69.Shishkin S, Kacevicius G, Ciocanu M. Evaluation of Moldova’s 2004 health financing reform Copenhagen: WHO Regional Office for Europe; 2008. [Google Scholar]
  • 70.dgMarket Tenders Worldwide [Internet]. Small contract award notice Mongolia (DIR, CQS, SSS). Chisinau: Health Services and Social Assistance Republic of Moldova; 2011. Available from: http://www.dgmarket.com/tenders/np-notice.do~6869115 [accessed 28 June 2013]. [Google Scholar]
  • 71.Djukić P. Serbia and DRG. In: EuroDRG [Internet]. EuroDRG Final Conference, Berlin, Germany, 17 November 2011. Berlin: Berlin University of Technology; 2011. Available from: http://www.eurodrg.eu [accessed 28 June 2013]. [Google Scholar]
  • 72.Bah S. Strategies for managing the change from ICD-9 to ICD-10 in developing countries: the case of South Africa. J Health Informatics Dev Countries. 2009;3:44–9. [Google Scholar]
  • 73.La facturation à la Caisse Nationale d'Assurance Maladie [Billing to the National Health Insurance Fund]. Tunis: Caisse Nationale d'Assurance Maladie; 2011. French. [Google Scholar]
  • 74.Akdag R. Health transformation program in Turkey: progress report (September 2010) Ankara: Ministry of Health Turkey; 2010. [Google Scholar]
  • 75.Reviews of health systems: Turkey Paris: Organisation for Economic Co-operation and Development; 2008. [Google Scholar]
  • 76.Paolillo E, Cabrera CD, Martins L, et al. Grupos relacionados por el diagnóstico (GRD): experiencia con IR-GRD en el Sanatorio Americano, sistema FEMI [Diagnosis-related groups (DRGs): experiences with the IR-DRG in the American Sanatory, FEMI system Diagnosis/related groups (DRGs): Experiences with the IR-DRG in the American Sanatory, FEMI system]. Rev Med Urug 200824257–65.Spanish [Google Scholar]
  • 77.United Nations University, International Institute for Global Health [Internet]. UNU casemix grouper now in Latin America Kuala Lumpur: UNU-IIGH; 2012. Available from: http://iigh.unu.edu/?q=node/104 [accessed 28 June 2013].
  • 78.Tangcharoensathien V, Patcharanarumol W, Pannarunothai S, Khiaocharoen O, Wisasa W, Greethong T. Key designs of financing reform: opportunities and challenges for Vietnam Bangkok: Ministry of Public Health; 2010. [Google Scholar]
  • 79.Tran V, Hoang T, Mathauer I, Nguyen T. A health financing system review of Vietnam with a focus on social health insurance Ha Noi: World Health Organization; 2011. [Google Scholar]
  • 80.Rechel B, Ahmedov M, Akkazieva B, Katsaga A, Khodjamurodov G, McKee M. Lessons from two decades of health reform in Central Asia. Health Policy Plan. 2012;27:281–7. doi: 10.1093/heapol/czr040. [DOI] [PubMed] [Google Scholar]
  • 81.Saleh K. A health sector in transition to universal coverage in Ghana. Washington: World Bank; 2012. [Google Scholar]
  • 82.Mathauer I, Wittenbecher F. DRG-based payment systems in low- and middle-income countries: implementation experiences and challenges Geneva: World Health Organization; 2012. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 83.Kutzin J, Ibraimova A, Jakab M, O’Dougherty S. Bismarck meets Beveridge on the Silk Road: coordinating funding sources to create a universal health financing system in Kyrgyzstan. Bull World Health Organ. 2009;87:549–54. doi: 10.2471/BLT.07.049544. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 84.Yip WC, Hsiao W, Meng Q, Chen W, Sun X. Realignment of incentives for health-care providers in China. Lancet. 2010;375:1120–30. doi: 10.1016/S0140-6736(10)60063-3. [DOI] [PubMed] [Google Scholar]
  • 85.Lazarevik V. Introducing DRG as a new reimbursement model for hospitals in the Republic of Macedonia Sofia: Ministry of Health; 2011. [Google Scholar]
  • 86.DRG Work Group Macedonia. DRG – diagnosis-telated groups: annual report 2009 Skopje: Health Insurance Fund Macedonia; 2010. [Google Scholar]
  • 87.Hanvoravongchai P. Health financing reform in Thailand: toward universal coverage under fiscal constraints Washington: The World Bank; 2013. [Google Scholar]
  • 88.Kutzin J, Cashin C, Jakab M. Implementing health financing reform: lessons from countries in transition. Copenhagen: WHO Regional Office for Europe; 2010. [Google Scholar]
  • 89.Albreht T, Turk E, Toth M, Ceglar J, Marn S, Brinovec RP, Schäfer M. Slovenia – health system review 2009 Copenhagen: WHO Regional Office for Europe; 2009. Available from: http://www.euro.who.int/__data/assets/pdf_file/0004/96367/E92607.pdf [accessed 28 June 2013]. [Google Scholar]
  • 90.Moreno-Serra R, Wagstaff A. System-wide impacts of hospital payment reforms: evidence from Central and Eastern Europe and Central Asia. J Health Econ. 2010;29:585–602. doi: 10.1016/j.jhealeco.2010.05.007. [DOI] [PubMed] [Google Scholar]

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