Title: Advancements in the DRG system payment: an optimal volume/procedure mix model for the optimisation of the reimbursement in Italian healthcare organisations

Authors: Cinzia Muriana; Giovan Battista Vizzini

Addresses: Istituto Mediterraneo per i Trapianti e Terapie Ad Alta Specializzazione (IRCCS – ISMETT), Via Tricomi 5, Palermo, 90127, Italy; University of Pittsburgh Medical Center (UPMC), Via Discesa dei Giudici 4, Palermo, 90133, Italy ' Istituto Mediterraneo per i Trapianti e Terapie Ad Alta Specializzazione (IRCCS – ISMETT), Via Tricomi 5, Palermo, 90127, Italy; University of Pittsburgh Medical Center (UPMC), Via Discesa dei Giudici 4, Palermo, 90133, Italy

Abstract: In Italy, the reimbursement provided to healthcare organisations for medical and surgical procedures is based on the diagnosis related group weight (DRGW), which is an increasing function of the complexity of the procedures. This makes the reimbursement an upper unlimited function. This model does not include the relation of the volume with the complexity. The paper proposes a mathematical model for the optimisation of the reimbursement by determining the optimal mix of volume/procedure, considering the relation volume/complexity and DRGW/complexity. The decreasing, linear, and increasing returns to scale have been defined, and the optimal solution found. The comparison of the model with the traditional approach shows that the proposed model helps the healthcare system to discern the quantity of the reimbursement to provide to health organisations, while the traditional approach, neglecting the relation between the volume and the complexity, can result in an overestimation of the reimbursement.

Keywords: diagnosis related group; DRG; healthcare reimbursement system; optimisation of the reimbursement function.

DOI: 10.1504/IJHTM.2024.140375

International Journal of Healthcare Technology and Management, 2024 Vol.21 No.2, pp.168 - 181

Accepted: 08 May 2019
Published online: 06 Aug 2024 *

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