More and more nations with developing economies are turning their attention to strengthening how they strategically purchase healthcare services. A key element gaining traction in this movement is the adoption of payment systems based on case-based groups (CBG), and particularly, diagnosis-related groups (DRGs). These systems are being explored by policymakers worldwide as potential tools to enhance efficiency and accountability in the health sector.
For those considering implementing a CBG system, a range of policy decisions and technical questions immediately arise. Leaders must carefully weigh the advantages and disadvantages of DRGs in the context of their specific national healthcare landscape and the unique challenges they aim to overcome. It’s essential to investigate the feasibility of introducing such a system, evaluating existing institutional frameworks and resource availability, and determining what additional resources might be necessary. It’s crucial to understand that this guide on CBGs and Diagnosis Related Groups is not promoting them as a singular, perfect solution, but rather as one of several options to consider when aiming to refine healthcare payment structures.
This guide is specifically designed to delve into the policy questions and challenges surrounding CBGs that are most pertinent to low- and middle-income countries. Presented in an accessible Question & Answer format, it provides references to further academic resources for deeper technical understanding and includes diverse country-specific examples to illustrate key points.
This document is structured into four distinct sections:
Part 1 establishes foundational definitions, key terminology, and core conceptual frameworks related to both CBGs and, more specifically, diagnosis related groups (DRGs). This section ensures a shared understanding of the basic building blocks of these payment systems.
Part 2 focuses on the crucial assessment phase. It highlights the essential questions and critical issues that policymakers must address comprehensively before deciding to embark on the implementation of a CBG system. Careful consideration at this stage is paramount.
Part 3 progresses into the preparation phase, thoroughly examining the policy and system design considerations that come into play once a country has made the strategic decision to adopt a CBG system. This section provides practical guidance on the steps involved in getting ready for implementation.
Part 4 addresses the implementation phase directly. It tackles the practical questions that arise during rollout, the necessary adjustments to existing systems, and the ongoing need for robust monitoring and evaluation. This continuous oversight is vital to identify and mitigate any unintended consequences of a CBG system and ensure its long-term effectiveness in utilizing diagnosis related groups.
