Case #675

DRG grouping of procedure code EGC30 Implant of jaw joint prothesis

Added by Anja Fagervold 28 days ago. Updated 4 days ago.

Status:ActiveStart date:2020-01-31
Priority:NormalSpent time:-
Assignee:Anja Fagervold
Category:-
Target version:Target version 2021
Initiator:Norway Target year:2021
Case type: Owner / responsible:National organisations
MDC:MDC03, MDC08 Old forum status:
Target Grouper:NOR

Description

Problem
With this case we want to initiate a discussion about an inquiry we got from the medical professionals in St.Olavs hospital and Oslo University hospital (OUS). They are concerned that the procedure EGC30 'Implantasjon av kjeveleddsprotese'/'Implant of jaw joint prothesis' is now grouped to DRGs with low costweights compared to the real costs and that this makes the treatment on this area in Norway not as good as in other comparable countries. In Norway this procedure is only performed on the two hospitals represented in this case.

The procedurecode EGC30, is now grouped to mainly three different DRGs depending on the diagnosis-code.

When diagnosed with K076 'Kjeveleddslidelser'/ 'Joint disorders':
- DRG 63 'Operasjoner på øre, nese, hals ITAD'/ 'Surgery on ear, nose, throat ITAD'
Cost weight 1,707 which would be about 3800 EUR (39 097 NOK) in ISF reimbursement.

When diagnosed with a code in HDG 8 (eg. M190 'Primær artrose andre ledd'/ 'Primary arthrosis of other joints') the cases will be grouped to DRG 233 or 234.
- DRG 234 Op på skjelett-muskelsystem og bindevev ITAD u/bk
Cost weight 2,016 which would be about 4500 EUR (46 174 NOK) in ISF reimbursement.
- DRG 233 Op på skjelett-muskelsystem og bindevev ITAD m/bk
Cost weight 3,523 which would be about 7900 EUR (80 690 NOK) in ISF reimbursement.

According to doctors at St.Olavs hospital and OUS, the cost of the implant alone is 5000-20 000 EUR (50 000- 200 000 NOK). In addition there will be costs for anesthesia, surgeon, stay in intensive care etc. They argue that this gap between the costs and the ISF- reimbursement gives this group of patients a treatment that is not satisfactory. Fewer patients than medically recommended will get a jaw joint prothesis due to the negative economics related to the treatment. It is also their experience that very few patient-specific implants are placed due to high cost and low DRG cost weights compared to in e.g. Sweden and Denmark, where patient-specific implants, so-called custom implants, are mainly used. According to their data Norway gives 20% of the patients patient-specific implants vs. 80% in Sweden/Denmark.

We are unsure of which is the optimal solution of DRG-grouping for this procedurecode and therefore want to discuss this issue with the expert group. How are these patients grouped and financed in the other Nordic countries?

Analysis
The number of implantation of jaw joint prothesis is yearly about 25 in Norway. This is not an accurate estimate of the real need because today very few patients with serious arthrosis or pain in the jaw joint gets the option of jaw joint prothesis. The need for jaw joint prothesis is estimated by the medical expertise to be maximum 60-70 a year in Norway.

Total cases Norway 2018: 21 (OUS)
Total cases Norway 2019 per 2. tert: 13 (11 OUS and 2 St. Olav)

2018:
DRG 234 – 18 cases
DRG 63 – 2 cases
DRG 233 – 1 case

2019 (by tert. 2):
DRG 234 – 10 cases
DRG 63 – 2 cases
DRG 233 – 1 case

Cost analysis
A "stock" prosthesis (not patient-specific) costs in purchases from 5000 EUR (50 000 NOK), a patient-specific implant costs from 8000-20 000 EURO (NOK 80-200 000), based on how the implant must be designed. These are planned based on CT images of the patient, and are specially designed so as to get the best possible match for each patient. This is in addition to other costs for anesthesiologist, surgeon, intensive care unit stay etc.

Cost information received from Oslo University hospital, procedurecode EGC30 :
- The implant alone costs on average 11 800 EUR (120 000 NOK) in 2018.
- The total cost per patient (KPO) is on average 27 000 EUR (274 235 NOK) for this group of patients.
- Average length of stay: 3,76
- Median length of stay: 3

Cost information received from St. Olavs hospital, procedurecode EGC30 :
- The implant alone costs on average 5400 EUR (55 000 NOK) in 2019.
- The total cost per patient (KPO) is on average 17 100 EUR (173 904 NOK) for this group of patients.

Suggestion
One option we are considering is giving the procedurecode EGC30 the property 03S01 'Major neck or head procedure', which means that the cases coded with the diagnosis K076 'Joint disorders' that are now grouped to DRG 63 with a cost weight of 1,707 will instead be grouped to DRG 49A 'Større operasjoner på ØNH ekskl.cochleaimplantat'/ 'Major surgery on ear, nose, throat' with a cost weight of 4,606, that would be about 10 300 EUR (NOK 105 495) in reimbursement.
This migh be an appropiate cost weight for this group of patients. It also makes sense medically that a implant of a jaw joint prothesis is a major procedure. Eg. the procedurecode EDB00 'Reseksjon av underkjeve'/ Resection of lower jaw' ' and EDB99 'Annet reseksjonsinngrep på underkjeve'/ 'Other resection surgery on lower jaw' now has the property 03S01 'Major neck or head procedure', while EGC30 has the property 03S12 'Other ear, nose, mouth or throat OR procedure' related to MDC 3. But this will not change the DRG-grouping of patients with a diagnosis within HDG 8. As stated initially we would like to hear how this is solved in other countries DRG Logic. See technical specifications for more specific information about the properties and grouping for the procedurecode EGC30 in the Norwegian DRG-logic.

Technical specification_case 675.xls (107 KB) Anja Fagervold, 2020-01-31 15:28

History

#2 Updated by Kristiina Kahur 4 days ago

Finnish National DRG-Centre/Kristiina Kahur 24-2-2020

In Finland, code EGC30 (EGSC30 ncsp+ code) has (in 2018) 28 cases a year, vast majority in DRG 580K Major mouth and jaw procedure, mean cost ca 15500 EUR.
Mean cost of DRG 580K is ca 11000 EUR (total # of cases 74, out of which 28 is EGC30 procedures). 15 have main dg K07.XX
The mean cost of DRG 580K w/o EGC30 cases is ca 9300 EUR.
Mean cost of DRG 063 is ca 5700 EUR.

Suggested DRG 049A would not be an option in Finland, because mean cost of DRG 049A is ca 6800 EUR.

Finnish cost data unfortunately do not support this change.

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