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What explains DRG upcoding in neonatology? The roles of financial incentives and infant health

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  • Jürges, Hendrik
  • Köberlein, Juliane

Abstract

We use the introduction of diagnosis related groups (DRGs) in German neonatology to study the determinants of upcoding. Since 2003, reimbursement is based inter alia on birth weight, with substantial discontinuities at eight thresholds. These discontinuities create incentives to upcode preterm infants into classes of lower birth weight. Using data from the German birth statistics 1996–2010 and German hospital data from 2006 to 2011, we show that (1) since the introduction of DRGs, hospitals have upcoded at least 12,000 preterm infants and gained additional reimbursement in excess of 100 million Euro; (2) upcoding rates are systematically higher at thresholds with larger reimbursement hikes and in hospitals that subsequently treat preterm infants, i.e. where the gains accrue; (3) upcoding is systematically linked with newborn health conditional on birth weight. Doctors and midwives respond to financial incentives by not upcoding newborns with low survival probabilities, and by upcoding infants with higher expected treatment costs.

Suggested Citation

  • Jürges, Hendrik & Köberlein, Juliane, 2015. "What explains DRG upcoding in neonatology? The roles of financial incentives and infant health," Journal of Health Economics, Elsevier, vol. 43(C), pages 13-26.
    • Handle: RePEc:eee:jhecon:v:43:y:2015:i:c:p:13-26
    DOI: 10.1016/j.jhealeco.2015.06.001
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    1. Reif, Simon & Wichert, Sebastian & Wuppermann, Amelie, 2018. "Is it good to be too light? Birth weight thresholds in hospital reimbursement systems," Journal of Health Economics, Elsevier, vol. 59(C), pages 1-25.
    2. Heike Hennig‐Schmidt & Hendrik Jürges & Daniel Wiesen, 2019. "Dishonesty in health care practice: A behavioral experiment on upcoding in neonatology," Health Economics, John Wiley & Sons, Ltd., vol. 28(3), pages 319-338, March.
    3. Brilli, Ylenia & Restrepo, Brandon J., 2020. "Birth weight, neonatal care, and infant mortality: Evidence from macrosomic babies," Economics & Human Biology, Elsevier, vol. 37(C).
    4. Simon Reif & Lucas Hafner & Michael Seebauer, 2020. "Physician Behavior under Prospective Payment Schemes—Evidence from Artefactual Field and Lab Experiments," IJERPH, MDPI, vol. 17(15), pages 1-37, July.
    5. Boes, Stefan & Napierala, Christoph, 2021. "Assessment of the introduction of DRG-based reimbursement in Switzerland: Evidence on the short-term effects on length of stay compliance in university hospitals," Health Policy, Elsevier, vol. 125(6), pages 739-750.
    6. Lai, Yi & Fu, Hongqiao & Li, Ling & Yip, Winnie, 2022. "Hospital response to a case-based payment scheme under regional global budget: The case of Guangzhou in China," Social Science & Medicine, Elsevier, vol. 292(C).

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    More about this item

    Keywords

    Hospitals; Reimbursement; DRG upcoding; Neonatal care; Preterm infants;
    All these keywords.

    JEL classification:

    • I11 - Health, Education, and Welfare - - Health - - - Analysis of Health Care Markets
    • I18 - Health, Education, and Welfare - - Health - - - Government Policy; Regulation; Public Health
    • D20 - Microeconomics - - Production and Organizations - - - General

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