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Presented by Emily Solomon

Diagnosis-Related Group (DRG)

  • Inpatient hospital reimbursement set according to patient's DRG.
  • Amount of payment per diagnosis
  • Predetermined fixed rate
  • Each DRG groups together principal diagnoses that have similar hospital resource use. (Shi & Singh 229).

Ex. Patient is admitted to the hospital, is given a diagnosis of hip fracture by medical team.

The hospital will receive X dollars of payment for patients care.

DRG as Case-based system

What is a Fracture of Hip and Pelvis?

DRG 536 without medical complications

  • Complete or incomplete fracture or break of the proximal femur (neck or head of femur), possibly involving the acetabulum of the pelvis.
  • Also known as Hip fracture
  • Single payments for all covered services associated with an episode of care.

  • Medicare uses DRG to reimburse hospitals for patients per classification of diagnosis. (Lee 51)

Management of Fracture of Hip and Pelvis

Medical services:

  • Radiology
  • Orthopedic Surgeon
  • Surgical and Operating Room needs
  • Physical Medicine
  • Nursing Care
  • Emergency Room
  • Medical Management

Surgical management

Post hospital care

  • Rehabilitation care
  • At Home or Rehab center

(Haentjens 1133)

Hospital cost for Fractures of Hip & Pelvis w/o Medical Complications- DRG 536

  • $9,403 Mean of inpatient hospital DRG-based reimbursement per person

(standard deviation SD $4,945)

(Schoushoe 940)

  • $11,299 Hospital costs per patient

(+- $4,808 SD) (Miura, L. 164)

  • Length of Hospital stay (LOS) 6.3 days (Schoushoe 940)

Have you broke your hip?

Not sure how to pay for the hospital and Rehabilitation expenses?

Health Insurance is the answer for you!

Will pay 80% of hospital costs once reach annual deductible of $4,000/year

Work Cited

Another reason for Health Insurance

Estimated Remaining Hospital bill: $2259.80 after meeting yearly deductible

Additional costs to consider:

  • Rehabilitation Facility
  • Skilled Nursing Home
  • Acute Rehabilitation Facility
  • Home Health Therapy
  • Follow-up doctors visits

Insurance Risk for Patient Population

Majority of this population aged 65 and older

Hip fracture can lead to signficant increase of morbidity and mortality in elderly (Miura 159)

Increase expense of post hosptial care

Increase need for therapy service

Medical services

Possible Long-term care services

It's a risky population to insurance...

Schoushoe, John T., et al. "Estimation of Standardized Hospital Costs from Medicare Claims That Reflect Resource Requirements for Care: Impact for Cohort Studies Linked to Medicare Claims." Health Services Research 49.3 (2014): 929-949. Academic Search Premier. Web 13 June 2015.

Shi, Leiyu, and Douglas A. Singh. Delivering Health Care in America A Systems Approach. Fifth ed. Burlington: Jones & Bartlett Learning, LLC, 2012. ***.

Miura, Lisa N., Albert R. DiPiero, and Louis D. Homer. "Effects Of A Geriatrician-Led Hip Fracture Program: Improvements In Clinical And Economic Outcomes." Journal Of The American Geriatrics Society 57.1 (2009): 159-167. SocINDEX with Full Text. Web. 15 June 2015.

Lee***

Haentjens, P., G. Lamraski, and S. Boonen. "Costs And Consequences Of Hip Fracture Occurrence In Old Age: An Economic Perspective." Disability & Rehabilitation 27.18/19 (2005): 1129-1141. Academic Search Premier. Web. 15 June 2015.

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