Challenges of implementing diagnostic‐related groups and healthcare promotion in Iran: A strategic applied research

Abstract Background and Aim Implementing the diagnostic‐related groups (DRGs) promotes the efficiency of healthcare. Therefore, the present study aimed to identify the challenges facing implementing the DRGs in Iran. Methods The present study is a strategic applied research conducted in two phases. In the first phase, the challenges facing DRGs were extracted through a literature review. Then the collected data is entered into a checklist consisting of five sections including technological, cultural, organizational, strategic, and natural challenges. In the second phase, data were collected by purposive sampling and semistructured interviews with 10 managers of the Medical Services Organization of Tehran, Iran. Data analysis was performed by conventional content analysis using MAXQDA software and descriptive using SPSS software version 19. Results The challenges facing the implementing DGRs from the experts' perspective included technological, organizational, nature, strategic, and cultural in order of priority. The three main fundamental challenges were reported; lack of integrating the DGRs with health information system (70%), frequent changes of management (70%), reducing the quality of care following early patient discharge (60%). Conclusion The results of the present study showed that the DRG system faced with challenges and healthcare officials should apply policies and guidelines to reform the system before changing the reimbursement system in Iran. By considering the leading countries experiences in the nationalizing the DRG system field, the problems and solutions of the system can be identified and aid in the more successful implementation of these systems.


| INTRODUCTION
The health system transformation with the aim of equitable distribution of health in society and increasing the quality of life of individuals has created the need to reform payment systems. 1 Since diagnostic related groups (DRGs) provide a framework for monitoring the quality of treatment and the consuming services in health centers, as well as cost control, it has received particular attention in most health systems. 2 DRGs were used to implement the prospective payment method in healthcare organizations in the 1980s and 1990s.
It has also been used as a tool for allocating adequate funding, measuring the productivity of health centers, comparing the performance of centers, and even epidemiological and research studies. 3 DRGs are a system of classifying patients based on personal characteristics, diagnoses, medical characteristics of patients, length of hospitalization, and the number of resources used and are the basis of a prospective payment system. 4 One of the benefits of this system is helping budget planning and benchmarking health service centers, helping to improve the general financial situation, utilization management, managing and planning and reducing future expenses, optimizing organizational and operational structures, improving the performance of the repayment system, and effectiveness in hospitals, and better allocation of financial resources. 5 In addition, it provides the possibility of predicting medical expenses and estimating the length of stay of patients. 6,7 DRGs were designed at Yale University in the late 1960s and were used as part of Medicare patient reimbursement. After reviewing the DRGs system, Medicare Severity was established that supported three distinct complication levels (substantial complication and comorbidities, complication and comorbidities, uncomplicated, and other diseases) to create clinically homogeneous groups. 8 The main structure of DRGs was then modified by considering four levels of severity of illness, which refers to the degree of loss of function or physiologic decompensation of an organ system and risk of mortality. The All Patient-Refined Diagnosis-Related Groups (APR-DRGs) classification is currently used for reimbursement in some European countries such as Belgium, Spain, Portugal and Italy, some Arab countries, and more than 30 states in the United States. 9 Germany's DRGs are regulated under the Australian DRGs under the name G-DRGS, 10 although DRGs are the primary means of reimbursement hospitals. However, it may jeopardize the main goals of hospital services, including the usual motivation set by DRGs to shorten a patient's stay in certain specialties, such as intensive care, which is high risk. Also, the grouping of diagnoses related to some specialties may not be considered accurate enough, such as psychiatric care, may not accurately predict costs, or calculate the cost of some infrequently provided hospital services, such as multiple trauma care. 11 On the other hand, the reimbursement accuracy and the beneficial relationship of the standard cost calculation plan depend on the budget's precise allocation and the calculation of a fair tariff by the hospital payment system. However, the allocation of budgets at the hospital level and the calculation of tariffs at the national level for relative hospitalization prices are rarely considered and evaluated in studies. 6 Also, due to the time-consuming determination of DRGs codes, preparing the relevant software should be considered in the planning related to the launch of this system. 12 Implementation of DRGs-based payment systems in some hospitals has been reduced, and in others, especially in the emergency department, increased. 13 This system in Japan has significantly reduced health costs and, consequently, resources. In addition, the average patients' stay has been reduced to 2.29 days. However, as in other countries, no improvement in the quality of care has been reported. 14,15 Studies have shown that, in addition to the benefits of using DRGs in reducing overuse of health services, reducing the length of stay, and controlling treatment costs, it has led to unintended consequences such as reduced quality of care, dumping, the need for recoding, and frequent hospitalizations. 16,17 The results of Barouni's review study 18 regarding the challenges and outcomes of the implementation of the DRG system showed that the most frequent issues were related to the increase in costs, the lack of adequate supervision and technical infrastructure, and the complexity of the method. Adverse outcomes decreased patient stay length, early patient discharge, admissions, services, and increased readmissions.
The results of Zeynep's study 19 aimed at investigating the issues and developments in the implementation of the DRG system in France. Conditions such as information systems, technical facilities, and adequate support are required to implement DRGs; there should be a document review committee to ensure compliance with relevant laws; in addition to personnel training, individuals need to be responsible for receiving relevant data, monitoring quality standards, and setting standards, and practical guidelines. During implementing the reimbursement system, while ensuring the stability of the hospital standardizing the data systems, the accuracy, comprehensiveness, and timeliness of data should be continuously monitored. 20,21 Therefore, on the one hand, considering the need to implement DRGs and their benefits, and on the other hand, the challenges of implementing this system, it is essential to be aware of the challenges before implementation in planning to reduce and eliminate it.
Therefore, this study aims to investigate the challenges facing implementing DRGs in Iran.

| METHODS
The present study is a strategic applied research conducted in 2020 in two phases. In the first phase the challenges facing DRGs were extracted through a literature review. For this purpose, the keywords of diagnosis-related groups, DRG, and challenge were used in PubMed, Scopus, and Web of Science databases until September 2020. The retrieved articles were evaluated by the research team and the challenges facing the DRG based on the data extraction form were retrieved from the relevant articles. [22][23][24][25][26][27][28][29][30][31][32][33] Then the collected data is entered into a checklist that its reliability was confirmed by the test−retest method and r = 0.8 and consists of five sections including: technological, cultural, organizational, strategic, and nature challenges. The questions in each section had four options: first priority, second priority, third priority, and none. In the second phase, data were collected by purposive sampling and semistructured interviews with 10 managers, all had bachelor's (BS) or higher degrees in health information management. Inclusion

| Results from interviews
Challenges facing the implementation of DGRs from the experts' perspective, in order of priority, included technological, organizational, nature, strategic, and cultural. Prioritizing the challenges is shown in Table 1.   DRGs are a method of classifying patients for health insurance purposes. In this system, patients are classified based on variables such as primary and secondary diagnosis, age, sex, complications, and treatments. Therefore, costs are controlled, and reimbursements are facilitated by third-party providers. 22 Although the main goals of DRGs-based reimbursement mechanisms vary around the world, increasing transparency and efficiency, providing effective care, controlling costs, and improving the quality of care are among the essential of these goals. However, these types of systems also encounter various challenges and unintended outcomes, including that hospitals tend to accept more cost-effective patients or pay more attention to cases that require outpatient care.
In some cases, patients are even discharged early to reduce costs. 14,17 More than half of the people mentioned a cultural challenge (decreasing the quality of care following early discharge) in the present study, consistent with the previous studies' results. It seems that policymakers and researchers should apply policies and guidelines to improve the DRGs payment system so that the quality of service delivery is not reduced while saving resources and costs.   and Canada shows that these countries have also benefited from US experience in implementing DRGs. 34 In general, a thorough understanding of international experiences with DRGs is essential to informing countries when developing and reviewing their national systems. 35,36 In this regard, technical and managerial capacity building at the national level is necessary to support the implementing DRGs. 31,37 In a study by Kotherova et al., 38   One of the limitations of the current study was the examination of the challenges of the DRG system based on the experiences of managers of the Medical Services Organization in Tehran, and it is difficult to generalize the findings to all professional groups or managers. Therefore, to achieve more rich results, it is suggested that the problems faced by the DRG system be examined from the perspective of managers and experts in other cities.

| CONCLUSION
The results of the present study showed that the DRG system faced with challenges and healthcare officials should apply policies and guidelines to reform the system before changing the reimbursement system in Iran. By considering the leading countries experiences in the nationalizing the DRG system field, the problems and solutions of the system can be identified and aid in the more successful implementation of these systems.

ACKNOWLEDGMENTS
The authors would like to thank the participating managers of the social security and medical services organization (Tehran, Iran), who devoted their time to participate in the study. This study was supported by Shahid Beheshti University of Medical Sciences, which contributed financial support.

CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
All data generated or analyzed during this study are included in this published article. All authors have read and approved the final version of the manuscript had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis. The data that support the findings of this study are available from the corresponding author, [Farkhondeh Asadi], upon reasonable request.

ETHICS STATEMENT
This study is approved under the ethical approval code of IR.SBMU.RETECH.REC.1400.520.

TRANSPARENCY STATEMENT
The lead author Farkhondeh Asadi affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.