This study proposes using relative weights (RW) of specific healthconditions or diagnoses as a simple tool to differentiate simple from not-simple diseasecases.
Using data from 1,558 records of closed chart review,conducted by Utilization Management and Third-party-payer Services (UM) of BangkokDusit Medical Services (BDMS) and a list of simple diseases advised by five healthinsurance partners, we compared discriminating power of various RW levels. Scenarioassessment was conducted to quantify number of cases that could be missed out andturn into risk management (RM) cases.
RW of 0.3 could categorize 22 (71%) of 31 conditions as simple diseases whileRW of 0.4 had the power to categorize 27 (87%) and RW of 0.8 could categorize 31 (100%)of the whole list. Scenario assessment showed increasing risk management (RM) casesfrom 8 cases using RW = 0.3 to 42 cases (5.3 folds) using RW = 0.4 and to 141 cases (17.6folds) when RW = 0.8 was used. Although greater RW threshold could capture greaterproportion of simple diseases, it could result exponentially increase of RM cases. As aresult, RW = 0.4 would be the optimum and practical cut-off point to differentiate simplefrom not-simple diseases. To monitor hospital performance, different levels of “Percentageof simple disease” should be applied due to different complexity (indicated by case mixedindex-CMI) of hospitals in BDMS network. We propose “Yellow zones” of 10%-20% forsuper tertiary care (CMI > 2.0), 40% - 50% for hub tertiary care (CMI 1.00 – 1.99), 60% - 70%for basic tertiary care (CMI 0.50 – 0.99) and 70% - 80% for secondary care (CMI < 0.5)hospitals. Only continuous monitoring is required when performance stays below theseyellow zones. However, when the proportion of simple disease is in the yellow zones,hospital management should pay specific attention. If the situation progressed and theproportion is higher than the upper limit of the yellow zone, special interventions ofhospital management and insurance partners would be urgently required.
Our data showed that RW of 0.4 was the optimum threshold todifferentiate simple from not-simple diseases as it could cover 87% of the current listof simple diseases with minimum number of possible RM cases. Different ranges ofproportions of simple diseases are proposed for different complexity of BDMS hospitalsaccording to their case complexity, reflected by case mixed index (CMI). More studiesusing data from other networks are recommended for broader application of this concept.
case-mixed index (CMI), relative weight (RW), simple disease, Bangkok Dusitmedical services (BDMS), private hospital, Thailand
Received: May 24, 2019
Revision received: June 8, 2019
Accepted after revision: June 28, 2019
BKK Med J 2019;15(2): 130-139.