Financial risk, hospital cost, and complications and comorbidities in medical non-complications and comorbidity-stratified diagnosis-related groups.

A number of methods are being studied to modify and improve the accuracy of the Medicare Diagnosis-Related Group (DRG) hospital classification system. This study analyzed resource consumption for 2,431 medical Medicare patients in the 53 non-complicating condition-stratified (i.e., non-complication and comorbidity) medical DRGs. Resource consumption per patient increased as the number of complications and comorbidities per patient per DRG increased, as measured by total hospital cost, hospital length of stay, the number of diagnoses and procedures per patient, the percent outliers, and mortality. Patients with more than four complications and comorbidities generated significant financial risk ($5,667 loss per patient) under DRG reimbursement. This study raises the question of the equity of DRG reimbursement for the medical non-complication and comorbidity-stratified DRGs. A method for DRG adjustment based on complications and comorbidities should be implemented by Congress to assure equitable payment for patients in these medical DRGs.