Patients classification System

tools for
Cost management

tools for
Quality management

tools for

4  Why to choose US

4  implementation


4  contact

4  Logic

4  diagnoses

4  procedures

4  inpatients

4  outpatients

4  insurance

4  readmissions

4  reoperations

4  complications

4  deaths

4  length of stay

4  day surgery

4  unjustified stays

Aim                                  To prevent sickness funds’ risk selection, to adjust for insured health status

Adjustment variables    207 diagnostic categories, based on ICD-10 diagnostic codes and/or inferred from ATC drugs codes according to recent recommendations:

Halfon P, Eggli Y, Decollogny A, Seker E. Disease identification based on ambulatory drugs dispensation and in-hospital ICD-10 diagnoses: a comparison. BMC Health Services Research2013,13:453.

4  diagnostic categories

185 procedure categories, based on ICD-9-CM procedure codes.

4  procedure categories

Adjustment models       Two classifications are available to allocate insured to mutually exclusive risk strata, based on main diagnosis (4  LOGIC), complexity (number of diagnostic categories), age, justified hospitalization

a)      Ambulatory diagnoses model (232 strata of risk)

b)      Full model (638 strata of risk)

A justified hospitalization correspond to any hospital stay, which is not candidate for one day surgery and not unjustified:

4  DAY surgery

4  unjustified stays

These classifications can be used prospectively (insured characteristics from year Y-1 or Y-2 to predict costs of year Y) or concurrently (insured characteristics and costs of year Y) with ambulatory and/or hospital costs.

Comments                        The user is free to choose the adjustment scheme. To avoid pernicious financial incentives, we recommend:

-     to used benchmark costs to avoid cost sharing

-     to exclude drugs’ inferred diseases if they reflect more medical practice than insured characteristics (see scientific paper of Halfon et al. above)

-     to equalize risk compensations for substitutable groups (e.g. caesarean section and vaginal delivery), similar interventions groups (e.g. mastectomy with or without mammal reconstruction) and minor or major operation for a same diagnosis (e.g. pneumectomy with or without thoracoscopy).


© Yves Eggli, 2016. Last update: 28.02.2016