A client is admitted with chest pain. A series of diagnostic tests are ordered, and the client undergoes coronary artery bypass grafting. The cost of care for this client is increased because of a four-pack-per-day smoking history that resulted in extension of the client’s intensive care unit (ICU) stay by 3 days because of respiratory problems. The case manager realizes that under the terms of the diagnosis-related group (DRG) payment system for this diagnosis that the client’s past history and present care needs will have what affect on reimbursement?

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A client is admitted with chest pain. A series of diagnostic tests are ordered, and the client undergoes coronary artery bypass grafting. The cost of care for this client is increased because of a four-pack-per-day smoking history that resulted in extension of the client's intensive care unit (ICU) stay by 3 days because of respiratory problems. The case manager realizes that under the terms of the diagnosis-related group (DRG) payment system for this diagnosis:

a.  the cost of caring for this client was $5000 greater than the DRG reimbursement fee, and the hospital will be allowed to collect the additional fees from the insurance company.

b.  although the cost of care for this client was greater than the DRG reimbursement amount, the hospital will be reimbursed only at the set fee.

c.  the client will be sued to pay back the insurance company for the extra fees incurred because smoking is a modifiable health risk for heart disease.

d.  the physician who admitted the client will receive a reduced payment to cover the loss incurred by the hospital.

b.  although the cost of care for this client was greater than the DRG reimbursement amount, the hospital will be reimbursed only at the set fee.

Explanation:

A DRG is a patient classification scheme that systematizes planned reimbursement to hospitals and promotes expenses containment actions. Usually, a DRG payment comprises all costs due to an inpatient stay since admission and until discharge.

However, since 1983, hospitals face financial losses due to exceeding the costs set by the DRG payment for a client's treatment. In the same way, they make a profit if costs are less than the DRG amount.

Under this system, hospitals are forced to reduce the patient´s stay when possible.