Development of Case Management System and Analysis of Economic Feasibility under the Fee-For-Service Reimbursement

Choi, Mi Young; Chae, Young Moon; Tark, Kwan Chul; Kim, In Suk; Chun, Ja Hae

Journal of Korean Society Quality Assurance Health Care 2004;11(1): 46.
Published online June 30, 2004.

행위별 수가 지불제도 하에서의 사례관리시스템 개발 및 경제성 분석

최미영¹, 채영문², 탁관철³, 김인숙⁴, 천자혜¹

¹연세대학교 의과대학 세브란스병원 적정진료관리실
²연세대학교 보건대학원 보건정보관리학과
³연세대학교 의과대학 성형외과학 교실
⁴연세대학교 간호대학 간호행정학 교실

Development of Case Management System and Analysis of Economic Feasibility under the Fee-For-Service Reimbursement

Mi Young Choi¹, Young Moon Chae², Kwan Chul Tark³, In Suk Kim⁴, Ja Hae Chun¹

¹Department of Quality Improvement, Severance Hospital, Yonsei University College of Medicine
²Yonsei University Graduate School of Public Health
³Department of Plastic & Reconstructive Surgery, Yonsei University College of Medicine
⁴Yonsei University College of Nursing

Abstract

Background
Recently, we have experienced various changes in the healthcare environment. Healthcare organizations are facing a financial crisis due to more competitive relationships among themselves as well with low health insurance fees. The purposes of the current study were: (1) to develop a data warehouse-based system for evaluating and monitoring the case management activities, and (2) to measure and analyze its effects.
Methods
In order to collect the data for the study, the database on discharged patients was utilized at a university hospital located in Seoul from June 1, 2002 through December 31, 2002. Initially, a data warehouse was built for the case management system. The case management activities were analyzed using structured methodology to establish the case management system.
Results
The findings of this study were as follows: (1) A case management system was developed to make it possible to monitor of healthcare quality and resource utilization. The Case management System included monitoring functions regarding utilization reviews, critical pathways, and clinical indicators. (2) Utilizing the case management system, unplanned readmissions were documented among total discharged patients during two months from November 1, 2002 through December 31, 2002. The unplanned readmission rate was 2.3%(276 patients) in total of 11,960 discharged patients. Among them 81 patients(0.7% of total discharges, 29.3% of unplanned readmission) were readmitted to the same physician in charge under the same diagnosis. No significant differences were found in the demographic variables such as gender and age among the patients. (3) After implementing the case management system, 2.9% of average length of stay reduced. Applying cost-benefit analysis, the 2.9% reduction of length of stay represents net profit of ${backslash}$ 279,592,000 in the year of 2004. In addition, applying value acceleration analysis, cumulative net benefit of ${backslash}$ 1,481,000,000 was expected by the year of 2007. Also we were able to expect ${backslash}$ 247,800,000 of cumulative benefit for the prospective 5 years in value linkage analysis. It represents average ${backslash}$ 787,700,000 of pure net benefit a year.
Conclusion
The value of present study would be not only implementing the knowledge management system into the existing case management activities, but also evaluating its effects and estimating its financial benefits. This study suggested that the case management system would be a supportive tool for monitoring and improving the quality of healthcare, and a cost-effective tool for increment of healthcare organization's financial benefit.

Key words Case Management;Data-Warehousing;Unplanned Readmission;Healthcare Quality Monitoring;Resource Utilization;Cost-benefit Analysis;Length of Stay;