THE EFFECT OF THE NEW TRAUMA DRGS ON REIMBURSEMENT

Reimbursement for trauma care based on prospective payment has not been satisfactory. The Health Care Financing Administration introduced four new Multiple Significant Trauma (MST) DRGs in 1991 with the intention of covering patients who have had at least two body sites injured. To determine the effect if any on reimbursement, a sample of patients who were assigned the new DRGs over a 5-month period were analyzed. The analysis compared the calculated reimbursement for these 49 patients based on their total accumulated charges, DRG weights, and the average Medicare dollar blend along with the additional weight factor specific for the study facility. This analysis was compared with an additional analysis determining the reimbursement performed on the same patient sample but with DRG weights determined from DRGs derived from the 1989 DRG GROUPER/FINDER. During the 5-month study period, 5.5% of the patients discharged from the hospital had sustained at least one injury covered by ICD-9-CM codes. Of these, 49 (3.9%) were classified into one of the four new MST DRGs. The majority of patients were male (75.5%), the mean age was 31.8 years, and the total charges accumulated were $1,809,192.23. The calculated DRG-based reimbursement was $1,183,495.40, or 65.5% of the total charges. In the second part of the study, using the DRGs available in 1989 for the same sample of patients, the DRG-based reimbursement was $691,437.72, or only 38.2% of the accumulated charges. The study suggests that the new MST DRGs apply to a very small percentage of trauma patients admitted to a level I trauma center, and that the DRGs are still not specific enough to describe the extent and severity of the injuries sustained, but that the overall reimbursement for the patients assigned these DRGs has improved. Further investigation is needed to improve the identification of patients with above-average charges and the influence of such factors as complexity of injuries, barriers to discharge, and combinations of injuries on eventual reimbursement when prospective payment is used.