[Using diagnosis-related groups in Chile: lessons and challengesLições e desafios do uso de grupos de diagnósticos relacionados no Chile].

Abstract

Objective: Analyze the implementation of diagnosis-related groups (DRGs) in Chile with a view to optimizing the distribution of public resources.

Methods: A chronological narrative analysis of the main milestones was complemented by simulated application of DRGs through emulated competition and cluster analysis for evaluative purposes.

Results: In 2001, DRGs were introduced in Chile in an academic context. The National Health Fund (FONASA) began using DRGs in the private sector. A public sector pilot was launched in 2015. After nearly two decades of progress, in 2020 FONASA established the DRG program as a payment mechanism for public hospitals. However, the COVID-19 pandemic slowed its development. In 2022, implementation was resumed. After evaluating the program, it was evident that the hospital clusters that had been predefined for differentiated payment did not successfully differentiate homogeneous groups. In 2023, the program was reformed, financing was increased, a single cluster and base rate were defined, and greater hospital complexity was recognized, compared to previous years. Three hospitals were added to the program, for a total of 68.

Conclusions: This experience shows that it is possible to sustain a public health financing policy that achieves greater efficiency and equity in the health system, based on the existence of robust institutions that continuously develop and improve.