Impact of DRG billing system on health budget consumption in percutaneous treatment of mitral valve regurgitation in heart failure

Figures & data

Table 1. Differences between DRG billing and average cost of hospitalization, the latter as a function of hospitalization length and cost per day as a proxy for clinical complexity. DRG 127 reimbursement = €3052.00.

	Theoretical cost per day of hospitalization, in Euros
Duration of hospitalization, days	450	500	550	600	650	700	750	800
3	1702	1552	1402	1252	1102	952	802	652
4	1252	1052	852	652	452	252	52	−148
5	802	552	302	52	−198	−448	−698	−948
6	352	52	−248	−548	−848	−1148	−1448	−1748
7	−98	−448	−798	−1148	−1498	−1848	−2198	−2548
8	−548	−948	−1348	−1748	−2148	−2548	−2948	−3348
9	−998	−1448	−1898	−2348	−2798	−3248	−3698	−4148
10	−1448	−1948	−2448	−2948	−3448	−3948	−4448	−4948
11	−1898	−2448	−2998	−3548	−4098	−4648	−5198	−5748
12	−2348	−2948	−3548	−4148	−4748	−5348	−5948	−6548
13	−2798	−3448	−4098	−4748	−5398	−6048	−6698	−7348
14	−3248	−3948	−4648	−5348	−6048	−6748	−7448	−8148
15	−3698	−4448	−5198	−5948	−6698	−7448	−8198	−8948

Data in the table are in Euros. Negative data means that costs exceed the reimbursement, generating a deficit per single case managed, as a function of the hospitalization length and average costs per day of hospitalization. DRG-related reimbursement and cost per day of hospitalization impact the estimates, which may vary in different regions of Italy and, furthermore, in different Countries.

Table 2. Estimates of global budget consumption based on the number of hospitalizations per year, for an average case of DRG 127 with hospitalization length of 9 days, with an average cost of €500 per day of hospitalization.

		Theoretical number of DRG 127/year
Given average case assuming a duration of hospitalization       of 9 days and a cost of 500 Euros per day of hospitalization		100	150	200
Number of hospitalizations per patient-year	Deficit generated as difference between DRG 127 billing and costs estimated for the given average case	Global budget consumption as: DRG127 billing + Deficit per number of cases/ year per number of hospitalizations/year
2	−€2896.00	−€283,494.00	−€428,294.00	−€573,094.00
3	−€4344.00	−€425,241.00	−€642,441.00	−€859,641.00
4	−€5792.00	−€566,988.00	−€856,588.00	−€1,146,188.00
5	−€7240.00	−€708,735.00	−€1,070,735.00	−€1,432,735.00

Global economic burden is reported as a function of the number of hospitalizations per case-year, global hospitalization costs per case as DRG billing plus deficit for the average case, computing the theoretical global budget consumption based on a number of cases per year (100, 150, and 200 in the simulation reported). DRG-related reimbursement and cost per day of hospitalization impact the estimates, which may vary in different regions of Italy, and furthermore in different Countries.

Table 3. Global budget consumption in the cohort of HF patients with symptomatic MR, based on DRG billing system.

Medical management (DRG 127)		Treatment by MTP (DRG 104)
Deficit simulated for an average case of DRG 127 with 9 days of hospital stay at a cost of €500 per day	€1,448.00	Deficit simulated for an average case of DRG 104 undergoing MitraClip, with 9 days of hospital study at a cost of €500 per day	€850.00
Hospitalizations expected per patient in 2 years	3.6	Hospitalizations expected in 2 years	10% of the cohort
Deficit times number of hospitalizations in 2 years for each case	€5,212.80	Deficit times number of hospitalizations in 2 years for each case	€2,890.00
Deficit estimated for the cohort of 34 HF patients	€177,235.20	Additional costs estimated for the cohort of 34 HF patients due to hospitalizations	€34,290.00
DRG-related billing costs for the 34 patients in 2 years considering the hospitalization rate	€373,564.80	DRG-related billing costs for the 34 patients in 2 years	€833,000.00
Global costs (DRG+deficit) in 2 years	€550,800.00	Global costs (DRG+deficit) in 2 years	€867,290.00
Global costs (DRG+deficit) in 8 years	€2,203,200.00	Global costs (DRG+deficit) in 8 years	€992,890.00

The table reports data generated in two scenarios: the column under DRG 127 represents the budget consumption for the medical approach (conservative), based on an average case and the number of hospitalizations per case-year as measured in the study; the column under DRG 104 represents the budget consumption simulated for an average case of a patient undergoing MR treatment by MTP, which is the Mitraclip trans-catheter procedure. The theoretical model takes into account a mean life expectancy of 8 years based on the Seattle Heart Failure Model (see text for details), and 10% of unplanned hospitalizations/year in the interventional scenario. Of note, the Seattle Heart Failure Model estimates mean life expectancy independently of MR. DRG-related reimbursement and cost per day of hospitalization impact the estimates, which may vary in different regions of Italy, and furthermore in different Countries.