#2920 - Topic 4 Reading Casemix Management In A New Hospital - Accounting in the New Public Sector

The information provided by casemix information systems mobilises new categories for construing medical activity (Bloomfield, 1991)

Can link IS usage to module 1 and the potential for outsourcing, improvements in IT, cloud computing etc.

Renders the work of clinicians visible and susceptible to intervention by management

Despite the perceived benefits of using casemix information for clinical audit and accountability, casemix information has tended to be used in the financing of health services and in the internal management of resources (Bloomfield et al., 1994)

• E.g. New Zealand and Australia

  • Used to observe volume, cost of activity and to improve the technical efficiency of hospital service delivery

Doolin focuses on the New Zealand Crown Health Enterprise Central Health

A computerized resource utilization system, linking costs to clinical activities

Emphasis shifted from generating financial information to distributing clinical casemix information

Foucault (1981) – power is viewed as both constraining and enabling

Casemix management is the management of clinical activity on the basis of a range of patient categories and the associated differential resource allocation (Bloomfield, 1991)

• Evaluation of particular product lines or producing departments in terms of profitability

• Enabling more rational decision making on resource allocation

• Determination of output levels

• Changes in production processes

• Performance appraisal of hospital subunits or even individual clinicians

The problem of health care is translated into one of a lack of the appropriate information required to control costs and to enable more efficient use of existing resources

• Implicit delegation to IT which involves keeping track of resource usage (Bloomfield, 1995)

Commonly used classification is Diagnosis Related Groups (DRGs)

• Classify and group together hospitals in-patients with similar principal diagnoses and treatment protocols, who are statistically similar in their length of stay

• Approx. 500 DRGs combines the clinical procedures, nursing care and diagnostic tests typically required to treat a medical condition

Average costs of the technical constituents of ear DRG are determined on the basis of standard costing

New Zealand costing based on comparison with Australian DRG cost data

Chua and Degeling (1991) describe hospitals as a ‘multi-product firm’

• Fetter and Freeman (1986) argue that the methods which produce improvements in private firms have potential for similar successes in hospitals

DRGs were developed in the US

Underlying the introduction of casemix management was a belief that much of the hospital’s resource expenditure was due to patient treatment decisions by clinicians

Casemix IS increase the transparency of professional knowledge, expertise and work processes

The deployment of comparative information provides management with both the technology and a rational justification for increased intervention in medical practice (Davies and Kirkpatrick, 1995)

‘the uninterrupted play of calculated gazes’ (Foucault, 1997) hints at the gaming and behavioural effects of monitoring

Bloomfield (1991) suggests that casemix management developments imply a blurring of the boundaries between management and medicine

Active cooperation of clinicians etc is required in the operation of such accounting and control systems designed to monitor medical activity (Coombs, 1987)

Historical financial focus on the casemix project at Central Health meant that clinical utilization of casemix information had been neglected

A quality discourse in an attempt to construct the interests of clinicians as congruent with those of management

• Translating the notion of patient care in terms of effectiveness and efficiency

  • “Effective is your quality”

  • “If you get into true effectiveness, meaning that your resources are being used appropriately… then you’re going to come out with efficiency” (Project leader interview)

Measures of length of stay, same day admissions, day surgery vs inpatient surgery etc. are some of the things the IS measured

Involved sharing the information, bringing it to a clinical person for clinical decision making

Analysis of variances in clinical activity based on casemix reports became more convincing than actual experience

One can question the extent to which genuine dialogue, particularly between managers and clinicians actually occurs in the complex negotiated order of the hospital

One of the most effective means of persuading doctors to change their clinical practice is to enable them to see their performance contrasted with others – using mirrors… (Edwards, 1992)

Attempts were made to use casemix information to encourage peer review among clinicians

Clinicial audit was a common interest that managesr could exploit in order to introduce the clinical casemix information to clinicians

• Clinical audit was required by the medical colleges and had an obvious connection with notions such as quality patient care

One consultant pointed out the difficulty in using clinical casemix information to compare individual clinicians with different sub-specialisations at a local level

Another consultant suggested that in order to be effective the comparative information used in the casemix reports had to more adequately reflect what the clinicians actually did

• He had a preference for the adoption of READ codes which are many times more detailed than DRGs

Managers in the Laboratory and Pharmacy believed that the key to appropriate use (‘better management’) of laboratory testing and drug prescription lay in containing the use of these resources by clinicians within defined treatment protocols

Reluctance of managers to challenge the long tradition of medical privilege and autonomy (Chua and Degeling, 1993; Pollitt, 1994)

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