Actual Costs Versus Diagnostic-Related Group Reimbursements for Unstable Angina: An Important Distinction for Effective Disease Management
Gian Paolo Bezante
Maria Rosalia Merello
Objective: Patients with unstable angina fall within a wide therapeutic and prognostic spectrum, and, in general, have access to specialty care and invasive procedures. Today, when hospital admissions for unstable angina outnumber those for myocardial infarction worldwide, and growing economic pressures are being placed on healthcare systems, cardiologists should re-examine clinical strategies for treating unstable angina in light of healthcare cost accounting. This study examines the number of patients with unstable angina hospitalised in our centre and the services supplied to them to determine the `real' cost regarding diagnostic and therapeutic procedures for these patients compared with the reimbursement rates established by the diagnosis-related group (DRG) system. Design and Setting: A patient schedule was drawn up to prospectively register the number and types of cardiac processes carried out during hospitalisation for all patients with unstable angina in the period between 1 March and 30 May 1996. The time (in minutes) actually spent by both physicians and nurses for each process was carefully recorded in order to calculate the `activity budget'. An `economic budget' was calculated for each cardiac process, taking into account salaries, materials, equipment maintenance, depreciation and indirect medical and nonmedical costs for hospitalisation in the coronary care unit and ward. Results: 53 out of 318 patients (16%) were discharged with a diagnosis of unstable angina. According to the DRG system, patients were allocated to 4 DRGs: DRG 140 (medically treated unstable angina; 18 patients); DRG 124 (unstable angina with angiography; 16 patients); DRG 122 (unstable angina evolving into myocardial infarction; 6 patients); DRG 112 (unstable angina with angioplasty; 13 patients). The mean cost for a hospitalised patient with unstable angina was 2911 euro (EUR): (DRG 140 = EUR1403.4; DRG 124 = EUR1462.2; DRG 122 = EUR3178.1; DRG 112 = EUR6658.3). The differences in costs were essentially related to the procedures involved in medical care; DRGs involving expensive cardiac processes had higher costs. Furthermore, these data show a marked discrepancy between `real' costs and current DRG reimbursements. Conclusions: The data show the standard management of unstable angina in our centre. Calculating the true costs of unstable angina is the first step towards maximising resources and optimising benefits. Our experience suggests that the use of this system is an essential means of creating an efficient management system for a cardiology unit. It should also be used to gather all the information necessary to establish whether reimbursement rates are covering real costs and to initiate the reduction of deficits or the utilisation of surpluses.
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