What are the opinions regarding the implementation of TARPSY in psychiatric institutions? The authors asked health care providers, hospital managers, and controllers about the strengths and weaknesses of the system.
The Swiss Health Insurance Act 2008 provides for the introduction of standardized remuneration systems for the whole of Switzerland. The costs are to be reimbursed on an activity-based and flat-rate basis. Based on legislation, Switzerland introduced a tariff system called TARPSY in the field of psychiatry in 2018.
Establishment and further development of the tariff system through SwissDRG
SwissDRG AG was commissioned to set up and further develop such a tariff system. It is a non-profit company founded by cantons, insurers and service providers.
The Swiss Federal Statistical Office (SFSO) annually collects a standardized data set, the “medical statistics of hospitals,” which had no tariff relevance until the introduction of TARPSY. All Swiss psychiatric hospitals were required to provide SwissDRG with this data as well as information on the costs per inpatient stay. The dataset contains relevant information on sociodemographic data, diagnoses and treatments. In addition, clinics should provide data for each patient based on the Health of Nation Outcome Scale; HoNOS is an internationally validated instrument for third-party assessment of the severity of psychiatric disorders in inpatient settings [1]. SwissDRG validated the data at the patient level [2].
The classification system is based on these data, with ten basic psychiatric cost groups (PCGs) classified based on the principal diagnosis in a first step. These cost groups are based on the main ICD-10 diagnosis categories (F0-9) plus an additional group for delirium treatment. Based on the variables, SwissDRG defined secondary diagnoses, age, and symptom intensity as cost-sharing factors. Currently, three elements of HoNOS determine symptom intensity: level of aggression, tendency to self-harm, and additional physical illness and disability. This allows the ten basic PCGs to be further differentiated into 23 PCGs. Although the legal basis is based on a flat fee, this could not be implemented for psychiatric disorders due to great variability in length of stay. The developers of the tariff system opted for a degressive system, whereby a cost weight multiplied by the length of stay of a given case yields the final tariff for that case.
Although TARPSY is a nationally standardized payment system, its payment structure, calculated from effective cost weights and prime rates, allows it to account for regional and structural differences among hospitals. SwissDRG emphasizes that TARPSY is a learning system that can be continuously improved based on new data.
How do care providers, hospital managers and controllers assess this tariff system one year after its implementation?
The role of the initial position
The tariff system brings different processes closer together. Health care providers such as physicians and psychologists and nurses rely on support from hospital administrators, coders and controllers, and vice versa. Providers complain that they receive too little support in coding. They attribute this to the fact that hospital executives assumed that a much smaller number of coders would be needed because of the few diagnostic categories in TARPSY. This is where the different starting positions and approaches of the clinics reveal themselves. On the one hand, there are hospitals that had already gained experience with DRGs or that were already introducing the system as test hospitals. On the other hand, there are service providers who have had no experience with the new system and sometimes did not provide data to the BfS or to the National Association for Quality Development in Hospitals and Clinics (ANQ) because they were not tariff-relevant before TARPSY. The latter now lacked the appropriate processes, which is why the introduction of TARPSY led to a disproportionate amount of additional work. Thus, some hospitals relied on professional coders from the beginning, other hospitals hired coders on a part-time basis, and still others handed over these tasks to their coders already working in DRG.
Differing levels of acceptance among the grass roots
Among the grassroots, i.e. those who work with female patients, the introduction of TARPSY led to uncertainty in some cases, with the time pressure often seen as an additional burden. Additionally, a sense of control emerged. This is attributed to the increased internal monitoring of the timing (finalization of the final report) and content (control of the main and secondary diagnoses) processes by Controlling. But the increased external retrospective monitoring of the content of diagnoses and, in particular, treatment by health insurers also contributes to the sense of control. This same review was viewed positively by some service providers. For example, some of the interviewees pointed out that this would entail a more detailed assessment of individual cases. For example, the intensity of care is better evaluated and remunerated. There has also been a greater awareness that documentation and exit reports need to be written more expeditiously . Perhaps this is why there is even a qualitative improvement in the documentation.
However, by allowing the physician to influence coding and thus reimbursement, some professionals feel pressured in their professional autonomy. Some service providers even see themselves forced by TARPSY to omit possible contents from the discharge report because they fear that they will not stand up to a later review by the health insurance company. Some hospitals have already responded to this by hiring physicians specifically as coders.
Proximity to DRG as a curse and a blessing
The changeover to TARPSY was based on the experience gained from the introduction of DRGs in 2012. Most clinics and other service providers in psychiatry were aware of the relevance of complete medical documentation as the backbone of economic planning. For this reason, many places started using professional coding staff early on. This is because the documentation no longer only serves the post-treatment physician, but also the coder as a basis for billing. In the introductory year, the test clinics and hospitals that had already adapted processes, personnel and data in advance were at an advantage. This data, collected in the previous year, now serves them as a basis for negotiation when talking to insurers. They can also use the data to react adequately to changes in earnings already in the current year.
The fact that much could be taken over from the introduction of DRG six years ago led at the same time to some disadvantages. The proximity to DRGs in the somatic sector was deliberately intended by SwissDRG in part to achieve uniformity across the various tariff structures, for example with regard to rules and definitions. But there are also differences, for example between DRG flat rates and TARPSY per diems.
The special features of psychiatry were given far too little consideration, as all the interviewees criticized. One explanation, he said, is the underrepresentation of psychiatrists in SwissDRG. Examples of the different trajectories in psychiatric treatments and the associated impact on the rate system included transfers to other hospitals, re-admission and review period, and assignment to the same MDC* for case pooling. In psychiatry, more often than in acute care, multiple diagnoses exist and fluctuate throughout the course of treatment. Therefore, other principal diagnoses are reported at re-entry in half of the cases. Similarly, somatic comorbidities and recurrences are disproportionately represented in psychiatry. The fact that too much reliance was placed on DRGs in somatics was also evident in stress leave, which is relevant to treatment in psychiatry. Patients are discharged there for short periods of time to test resilience; however, their bed must be ready at all times. Until the end of 2019, these vacations will still be financially cushioned with a surcharge. For the time after that, clinics need to find a solution for dealing with stress leave.
More expense and economization of psychiatry?
All interview partners were able to confirm an increase in administrative work. Even though the more expeditious process in the preparation of the exit report and in terms of uniformity was positively highlighted, at the same time no one could observe a real increase in efficiency due to TARPSY. On the contrary, the additional workload in terms of personnel and processes is criticized. Many fear a further increase in administration, especially with regard to the Swiss surgical classification (CHOP). For example, they are considering simply omitting certain codes, such as complex care treatment, and deliberately not claiming the additional charge defined for this. It is questionable whether the costs incurred for the services are adequately compensated and whether the discharge report does not degenerate into a coding report instead of documentation for the post-acute care provider.
The interviewees expressed their concerns that patients would suffer further disadvantages from the new financing system. The issue, as with DRG, is the economization of psychiatry. There is a fear that this will create the wrong incentives. Psychiatrists see themselves as having a responsibility to prioritize the treatment of their patients, whereas TARPSY acts as an economically, not medically, driven system.
A first conclusion
The interviews revealed different levels of knowledge and different starting points among institutions and professional groups. One could sum up: The higher the level of knowledge and the more detailed the data at the beginning, the smoother the introduction and implementation of the system.
The advantages of TARPSY are primarily seen in its standardization, comparability and transparency. TARPSY has also brought benefits in terms of improved quality of discharge reports for most mental health providers. However, these are associated with a disproportionate additional administrative burden.
In terms of content, some processes are still unresolved at TARPSY. Here, the interviewees referred to the definition of the main diagnosis in the case of re-entries, as well as to the change of health insurer, change of canton or the problem of long-stay patients. Uncertainties also exist with regard to the further development of CHOP codes. The goal of further development of CHOP codes as a replacement for HoNOS is to improve cost segregation in patient care, related to additional effort and intensity of treatment. This goal can only be achieved by having good data.
It is important, as SwissDRG repeatedly emphasizes, to understand TARPSY as a learning system. The interviews reveal the need to harmonize the information situation of psychiatric institutions and to provide comprehensive data in order to continue providing high-quality patient care. At the same time, the ethical responsibility and professional autonomy of female physicians should not be put under pressure by the tariff system. The future will show whether the learning system TARPSY is up to these challenges.
* Major Diagnostic Category. Only one MDC exists for TARPSY.
We thank the following institutions for their time and valuable input:
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Literature:
- Andreas S, et al: The validity of the German version of the Health of the Nation Outcome Scales (HoNOS-D): clinician-rating for the differential assessment of the severity of mental disorders. International journal of methods in psychiatric research 2010; 19(1): 50-62.
- Schneeberger AR, et al: TARPSY: A New System of Remuneration for Psychiatric Hospitalization in Switzerland. Psychiatric Services 2018; 69(10): 1056-1058.
InFo NEUROLOGY & PSYCHIATRY 2019; 17(2): 37-39.
