Diagnosis-related group prospective payment. Effects on medical quality assurance

The new system for hospital reimbursement, called "reimbursement by diagnosis-related group" (DRG), offers a unique opportunity for the development of novel approaches to quality assurance. Groups of medically similar patients with stable patterns of resource use have been defined. These groups form the basis of the new payment system. Patients whose care deviates from the norm of resource consumption for their group, so-called outliers, will need to be reviewed by the hospital's administrative and medical staff. Such outliers are likely to constitute different types of patients than those in their assigned group: (1) patients whose medical complexity precludes grouping because of limitations in the abstracted clinical data; (2) patients whose medical care deviated because of complications of therapy or inappropriate diagnostic and/or therapeutic interventions; (3) patients whose medical course is so unique that they would never fit any classification system. The DRG-based reimbursement system, then, will compel hospitals to review the care of these outliers. The rigorous examination of these patients and their care, although just a first step, should be a major boon to quality of care evaluations.