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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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    References listed on IDEAS

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    1. Shigeoka, Hitoshi & Fushimi, Kiyohide, 2014. "Supplier-induced demand for newborn treatment: Evidence from Japan," Journal of Health Economics, Elsevier, vol. 35(C), pages 162-178.
    2. Douglas Almond & Joseph J. Doyle & Amanda E. Kowalski & Heidi Williams, 2010. "Estimating Marginal Returns to Medical Care: Evidence from At-risk Newborns," The Quarterly Journal of Economics, Oxford University Press, vol. 125(2), pages 591-634.
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    5. Matthias Vogl, 2012. "Assessing DRG cost accounting with respect to resource allocation and tariff calculation: the case of Germany," Health Economics Review, Springer, vol. 2(1), pages 1-12, December.
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    7. Randall P. Ellis & Thomas G. McGuire, 1993. "Supply-Side and Demand-Side Cost Sharing in Health Care," Journal of Economic Perspectives, American Economic Association, vol. 7(4), pages 135-151, Fall.
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    Cited by:

    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. Hafner, Lucas & Reif, Simon & Seebauer, Michael, 2017. "Physician behavior under prospective payment schemes: Evidence from artefactual field and lab experiments," FAU Discussion Papers in Economics 18/2017, Friedrich-Alexander University Erlangen-Nuremberg, Institute for Economics.
    3. Hennig-Schmidt, Heike & Jürges, Hendrik & Wiesen, Daniel, 2018. "Dishonesty in healthcare practice: A behavioral experiment on upcoding in neonatology," HERO On line Working Paper Series 2018:3, Oslo University, Health Economics Research Programme.

    More about this item

    Keywords

    Hospitals; Reimbursement; DRG upcoding; Neonatal care; Preterm infants;

    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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