A diagnosis-related group (DRG) is a grouping of patients who are anticipated to have similar needs, based on their diagnoses, treatments so far, and profiles in terms of age and prospective discharge date. There are a number of different systems used for categorizing diagnosis-related groups in hospital and clinical settings, and they are used for activities like balancing a hospital's caseload and determining what kind of reimbursements hospitals are eligible for from government insurers, as well as private insurance companies. They can also be used to track patient outcomes and hospital caseloads.
A common classification system is the one used by Medicare in the United States, where there are more than 500 diagnosis-related groups. Each group is based on why a patient is in the hospital and what kind of procedures have been performed, with further considerations like age and complications. For example, “craniotomy for a patient greater than 17 years of age” is a diagnosis-related group. People in this group are expected to use similar levels of hospital resources.
For hospitals, balancing caseloads is important to make sure they have the staff, equipment, and facilities they need to provide appropriate case. Using a diagnosis-related group system, hospitals can monitor their patients and see what kinds of resources they have available. While every patient is different, people with similar underlying conditions and procedure histories tend to use similar levels of resources, ranging from personnel to imaging equipment.
Some insurance providers use a pay for performance system and track progress at facilities using diagnosis-related group systems to determine how much a facility should receive in compensation. One advantage to standardized systems like this is the elimination of falsified or inflated records; if everyone within a group is expected to consume the same amount of resources, a base payment can be provided for each member of the group to cover associated expenses. Looking at performance within these groups can also be useful for seeing how well a facility is meeting care goals.
These grouping systems are very large, recognizing the huge numbers of reasons people seek treatment and the potential for complications and comorbidities. Patients may move between diagnosis-related groups as a result of changes in their conditions or cases, as seen when a patient develops severe complications requiring more medical interventions. The diagnosis-related grouping of a patient is a matter for internal records, and patients are usually not told which diagnosis-related group they are in.
