The document discusses clinical pathways and their relationship to diagnosis related groups (DRGs) and casemix in determining the cost of treatment. It proposes developing clinical pathways based on the existing ICD classification system and major diagnostic categories (MDCs) to standardize quality of care and establish a basis for planning costs and reimbursement rates. Tables are provided as examples to illustrate how clinical pathways could be used to track resource utilization and estimate costs for different activities in the treatment process.

1. C linical Pathway & Cost of
Treatment
(Conceptual Thinking & Application)
Ronnie Rivany ®
Health & Hospital Economics
Pusat Kajian Ekonomi & Kebijakan Kesehatan FKMUI

2. JASTIFIKASI
• Standarisasi tarif RS ?
• Belum ada Clinical Pathway sebagai penjaga
mutu & sebagai basis layanan MUTU dan
basis perencanaan/perhitungan biaya
• Sistem, Kebijakan dan Prosedur yang tidak
jelas dan tidak konsisten serta belum
terintegrasi
• Buku Tarif Departemen Kesehatan 2007 (?)

3. Major Diagnostic Categories (AR-DRG v 5,2, 2006)
1 Diseases and disorders of the nervous system
2 Disease and disorders of the eye
3 Disease and disorders of the ear, nose, and throat
4 Disease and disorders of the respiratory system
5 Disease and disorders of the circulatory system
6 Disease and disorders of the digestive system
7 Disease and disorders of the hepatobiliiary system and pancreas
8 Disease and disorders of the musculoskeletal system and connective tissue
9 Disease and disorders of the skin, subcutaneous tissue, and breast
10 Endocrine, nutritional, and metabolic diseases and disorders
11 Disease and disorders of the kidney and the urinary tract
12 Disease and disorders of the male reproductive
13 Disease and disorders of the female reproductive system
14 Pregnancy, childbirth, and the purperium
15 Newborn and other neonates with conditions originating in the perinatal period
16 Disease and disorders of blood and blood forming organs and immunological disorders
17 Myeloproliferative disease and disorder, and poorly differentiated neoplasm
18 Infectious and parasitic disease (systemic or unspecified sites)
19 Mental diseases and disorders
20 Alcohol/drug use and alcohol/drug- induced organic mental disorders
21 Injuries, poisoning, and toxic effects of drugs
22 Burns
23 Factors influencing health status and other contact with health services

4. DRG Numbering
• The format = A DD S
• A = Pre MDC DRG’s ; B = nervous system
DRG; O = Reproductive System; Z = DRG’s
relating to other health factors; 9 = the error
DRG’s
• DD = DRG’s partition;
– Range 01 – 39 Surgical Partition
– Range 40 – 59 Other Partition
– Range 60 – 99 Medical Partition
• S = split indicator
– A = highest resources DRG
– B = second highest resources

5. General Logic,
All acute admited patien Diagnosis Related Group’s
Principal diagnosis
Major diagnostic category # 1 MDC # 2 MDC # 3 MDc # 4
Yes No
Surgical Partition of MDC # 1 Medical Partition of MDC # 1
What procedure
Procedure Procedure Procedure Procedure
Custer A Cluster B Cluster C Cluster D
What age group’s
Over Under X
Procedure cluster A over age X Procedure cluster A under age X
Significant secondary condition ?
Yes No
Procedure cluster A Procedure cluster A
Over Age X, with CC Over Age X, without CC

6. INDONESIAN DRG’s

8. INDONESIAN DRG’s
• Pola pikir
– ICD tetap
– MDC untuk sementara tetap
– Clinical Pathway bisa dibuat
– DRG di konfirmasi + bisa dibuat
– Casemix di konfirmasi + bisa dibuat
– Costing dilakukan dengan pendekatan
Activity Based Costing + Simple
Distribution

9. POLA PIKIR INDONESIAN DRG’s (1)
INA - DRG
1.Konfirmasi DRG 2.Hitung Cost/DRG
Clinical Pathway & Casemix
Activity Based Costing

10. POLA PIKIR INDONESIAN DRG’s (2)
ICD
MDC
1
DRG DRG DRG
2 COST CASEMIX
TARIF COST
TARIF

11. Clinical Pathway
• Anticipated Recovery Pathway (ARPs)
• Multidisciplinary Pathways of Care (MPCs)
• Care Protocols
• Integrated Care Pathways
• Pathways of Care
• Care Packages
• Collaborative Care Pathways
• Care Maps
• Care Profiles

12. Konsep perencanaan pelayanan
terpadu yang merangkum setiap
langkah yg diberikan kepada pasien
berdasarkan standar yanmed,
standar asuhan keperawatan&
standar pelayanan tenaga kesehatan
lainnya , yg berbasis bukti dng hasil
yg dpt diukur dan dalam jangka
waktu tertentu selama di rumah sakit

14. Major Diagnostic Categories (Pedoman Tarif ?? DEPKES,2007)
1 Diseases and disorders of the nervous system
2 Disease and disorders of the eye
3 Disease and disorders of the ear, nose, and throat
4 Disease and disorders of the respiratory system
5 Disease and disorders of the circulatory system
6 Disease and disorders of the digestive system
7 Disease and disorders of the hepatobiliiary system and pancreas
8 Disease and disorders of the musculoskeletal system and connective tissue
9 Disease and disorders of the skin, subcutaneous tissue, and breast
10 Endocrine, nutritional, and metabolic diseases and disorders
11 Disease and disorders of the kidney and the urinary tract
12 Disease and disorders of the male reproductive
13 Disease and disorders of the female reproductive system
14 Pregnancy, childbirth, and the purperium
15 Newborn and other neonates with conditions originating in the perinatal period
16 Disease and disorders of blood and blood forming organs and immunological disorders
17 Myeloproliferative disease and disorder, and poorly differentiated neoplasm
18 Infectious and parasitic disease (systemic or unspecified sites)
19 Mental diseases and disorders
20 Alcohol/drug use and alcohol/drug- induced organic mental disorders
21 Injuries, poisoning, and toxic effects of drugs
22 Factors influencing health status and other contact with health services
23 Medical Outpatient Visit

15. HUBUNGAN C.P & DRG/CASEMIX
ICD
MDC
Clinical Pathway
DRG DRG DRG
COST CASEMIX
TARIF COST
TARIF

16. Clinical Pathway in Hospital

17. Pengembangan Konsep
Clinical Pathway
International Classification of Disease (ICD)
Major Diagnostic Categories (MDC)
Clinical
Pathway Surgical / Other / Medical
Diagnosis Related Groups (DRG’s)
Casemix

18. Format dasar Clinical Pathway
Aktivitas pelayanan Pra R.I Rawat Inap (R.I)
(Poliklinik/ Hari I Hari 2 Komplikasi
UGD) Tgl Tgl /
Co-
morbidity
1 2 3 4 5
Pendaftaran
Penetapan Diagnose
Pra-Perawatan
Perawatan
Tindak Lanjut

19. CLINICAL PATHWAY DALAM
TAHAPAN PRA PERAWATAN & PERAWATAN
Aktivitas pelayanan Pra R.I Rawat Inap (R.I)
(Poliklinik/
UGD) Hari I Hari 2 Komplikas
Tgl Tgl i/
Co-
morbidity
1 2 3 4 5
Pra-Perawatan
Assessment klinis
• pemeriksaan/visite dokter
• konsultasi
Pemeriksaan penunjang
• laboratorium
• Radiologi
• Dst sesuai SPM, SAK & SPO
Perawatan
• Tindakan medis
• Pemberian obat
Dst-nya, sesuai SPM,SAK & SPO

20. DUMMY TABLE (1)
Clinical Pathway Utilisasi
No SOP Hari.1
Diag.Utama + Serta + Sulit +
Serta
+ Sulit
1 Admission
2 Diagnostic
3 Pra Therapy
4 Therapy
5 Follow Up
6 Discharge

21. DUMMY TABLE (2)
Clinical Pathway Utilisasi
No Aktivitas SDM OBAT OVERHEAD
1 Admission
2 Diagnostic
3 Pra Therapy
4 Therapy
5 Follow Up
6 Discharge

22. DUMMY TABLE (3)
Clinical Pathway Utilisasi
No Aktivitas Min Max Mean /
Utilisasi Utilisasi Median
Utilisasi
1 Admission
2 Diagnostic
3 Pra Therapy
4 Therapy
5 Follow Up
6 Discharge

23. CLINICAL PATHWAY
SYMPTOM DIAGNOSIS THERAPY FOLLOW UP
1 2 3 4 5
Admission Diagnosis Pre Therapy Therapy Follow up
Activities Activities Activities Activities Activities
ABC ABC ABC ABC ABC

24. PEMBUATAN CLINICAL PATHWAY (1)
• Diawali dengan membuat template untuk
mendapatkan clinical pathway. Langkah-
langkah dalam membuat clinical pathway
adalah sebagai berikut :
• Membuat koding untuk memudahkan entry
data.
• Entry data karakteristik, identitas, tanggal
masuk dan keluar rumah sakit, lama hari
rawat, jenis pembayaran, diagnosa utama,
penyakit penyerta, penyakit penyulit, cara
masuk, status keluar dan kelas rawatan dari
masing-masing pasien. Entry data dilakukan
berdasarkan kelompok AR-DRG.

25. PEMBUATAN CLINICAL PATHWAY (2)
• Entry semua aktivitas yang diterima pasien dari masuk
sampai pulang dan pada waktu rawat jalan. Semua
aktivitas dekelompokkan berdasarkan tahap clinical
pathway.
• Konfirmasi tahap clinical pathway dan variabel
kegiatan dengan SPM IDI, SPM Profesi dan para
dokter dan paramedis di Rumah Sakit .
• Draft clinical pathway diisi berdasarkan frekuensi
masing-masing kasus.
• Berdasarkan nilai mean atau median didapatkan nilai
rata-rata masing-masing variabel dalam clinical
pathway perhari rawatan berdasarkan kelompok AR-
DRG.
• Cleaning dan pengecekan ulang terhadap nilai
utilisasi berdasarkan tahap dalam clinical pathway
masing-masing kelompok AR-DRG sehingga
didapatkan nilai utilisasi kelompok AR-DRG
berdasarkan clinical pathway.

26. PEMBUATAN CLINICAL PATHWAY (3)
Draft & Finalisasi Clinical Pathway
• Setelah draft Clinical Pathway yang
berbasis evidence tadi telah dibuat,
maka tahapan akhir dari penyusunan
Clinical Pathway ini adalah Focus Group
Discussion dengan Panel Expert ( para
spesialis ) dan Ikatan Profesi , untuk
bersama-sama menyepakati jenis dan
jumlah tindakan/FORMULARIUM
yang akan dipergunakan dalam Clinical
Pathway

27. DUMMY TABLE (1)
Clinical Pathway Cost of Treatment
Activities Day.1 Day.2 Day.3 Day
…..
Admission + + + +
Diagnosis + + + +
Pre Therapy + +
Therapy + + + +
Follow Up
Discharge

28. DUMMY TABLE (2)
Clinical Pathway Cost of Treatment
No Activities Day.1
Principal Penyulit Penyerta PP
Diagnosis
1 Nursing
2 Consultation
3 Doctor visits
4 Medical Procedures
5 Nursing
6 Medical /DRUGS
Treatment
7 Supporting exams
8 Nutrition
9 Physiotherapy
10 Etc

29. DUMMY TABLE (3)
Clinical Pathway Cost of Treatment
No Activities U DC IC TC UC U x UC
1 Admission
2 Diagnosis
3 Pre Therapy
4 Therapy
5 Follow Up
6 Discharge
TOTAL C/DRG

30. Cost of Treatment
(Cost DRG/Casemix)
No Cost of Treatment / Direct Cost IndirectCost
Activity Based Investasi Operasional Pemeliharaan INDEX
Costing
1 Admission %
2 Diagnostic %
3 Pra Therapy
%
4 Therapy %
5 Follow up %
6. Discharge

31. APLIKASI COST/DRG/Casemix dalam PK BLU(1)
Cost of Treatment Rawat Inap dan Rawat Jalan
No AR-DRG KLS. III KLS. II KLS.I UTAMA VIP RAJAL
1 B70A 5181485 5281384 5339924 5778045 5805053 803121
2 B70B 4075179 4153671 4199667 4543904 4565126 995167
3 B70C 1905273 1976629 2018443 2331386 2350678 987047
4 B70D 1848767 1863038 1871401 1933989 1937848
Perbandingan Biaya Rawat Inap KLS.III
No AR-DRG KLS. III Tanpa Gaji Tanpa Obat Tanpa Gaji
Dan Obat
1 B70A 5181485 4250350 2972007 2040872
2 B70B 4075179 3476706 2250808 1652334
3 B70C 1905273 1489521 1438879 1023127
4 B70D 1848767 1624600 1030735 806568

32. CLINICAL PATHWAY COST of TREATMENT

33. TARIFF DETERMINANT per DRG’S
TARIFF
Margin
COST/DRG’s
UNIT COST UNIT COST UNIT COST UNIT COST UNIT COST
ROOM & BOARD DRUGS LAB MED SUPPLIES OK
Total cost Q
ACTIVITY BASED COSTING + SIMPLE DISTRIBUTION

34. LAPORAN
Clinical Pathway & Cost of Treatment
Diagnosis Related Group (DRG’s)
Sectio Caesaria, Diare Anak & Katarak (2008)
Apendictomy & Pneumonia Anak (2009 - 2010)
DINAS KESEHATAN
Pemerintah Propinsi Daerah Khusus Ibukota Jakarta

35. REKAM MEDIK DI RUMAH SAKIT

36. LAPORAN
Clinical Pathway & Cost of Treatment
Diagnosis Related Group (DRG’s)
10 Dept – International Wing
2009 - 2010
RUMAH SAKIT
Dr Cipto Mangunkusumo, Jakarta

37. LAPORAN
Clinical Pathway & Cost of Treatment
Diagnosis Related Group (DRG’s)
Rumatan Methadon, 2010
RUMAH SAKIT KETERGANTUNGAN OBAT
Cibubur - Jakarta

38. DIREKTORAT JENDERAL BINA PELAYANAN MEDIK
DEPARTEMEN KESEHATAN
2005

39. • RS wajib memp.CP, Diagnosis mengacu
pada ICD-10,Prosedur mengacu pd ICD-
9CM Flowchart penyusunan CP
ICD
SPM Profesi Model Dummy
Surgical Medical
SPM RS Clinical Pathway
Terukur(admissi
on to discharge) DRG
contoh :
-Diare anak
SOP Aktivitas -Sectio Caesaria
Case Mix

40. TUJUAN :
• utk meningkatkan mutu Yan pasien
• memaksimalkan penggunaan sumber daya
scr efisien dng mengurangi dokumentasi yg
tdk diperlukan.
• membantu identifikasi & klarifikasi proses
Yan klinis
• mendukung efektivitas klinik, audit medis &
risk management

41.  Dalam menyusun clinical pathway (C.P) di RS peru
memadukan & menyesuaikan dng b’bagai sistem yg
tlh dibangun serta tlh b’jalan sehingga stiap bagian
yg ada di RS lebih mudah menyesuaikan & saling
mendukung pd saat C.P. selesai dibuat &
disosialisasikan.
 Komite Medik sngt bperan dlm m’bantu penyusunan
& plaksanaan C.P. di RS.
 Pedoman C.P. di RS diharapkan dpt m’bantu RS dlm
menyusun C.P. dlm rangka mendukung plaksanaan
pengembangan DRG’s Casemix di RS.

42. TERIMA KASIH
atas perhatian & kesempatan
kerjasamanya
www.ina-drg-rr.net