Case mix complexity is not recognized in adjusted patient days and adjusted discharges. endstream endobj 138 0 obj <>/Metadata 16 0 R/OCProperties<>/OCGs[146 0 R]>>/Outlines 23 0 R/PageLayout/SinglePage/Pages 135 0 R/StructTreeRoot 32 0 R/Type/Catalog>> endobj 139 0 obj <>/ExtGState<>/Font<>/Properties<>/XObject<>>>/Rotate 0/Tabs/S/Type/Page>> endobj 140 0 obj <>stream Laboratory costs analyzed included clinical chemistry, microbiology, reference testing, molecular diagnostics, and hematology. If the metric provides a better assessment of actual hospital volume than does either of the other metrics, one also can expect that using Equivalent Discharges to assess of the causes for hospital cost payment increases will produce findings very different from those derived from using either of the other two metrics. Wu AH, Lewandrowski K, Gronowski AM, et al. It is calculated by summing the DRG weights for all Medicare discharges It should be noted that the income from patient services reported here is larger than final net income from all sources for the industry. Using the traditional metric cost per test, we saw a sharp rise in cost per test for molecular diagnostic and reference laboratory testing, despite cost-saving initiatives used during the entire time period, 2010 to 2016 Figure 1. Actual hospital payments increased 27percent from 2011to 2016, which exceeded the rate of increase in total national health expenditures (24percent). Test menu changes, physician education, and laboratory utilization feedback were used to address costs and overused tests. This analysis refutes this conclusion, finding that 84percent of the increase in actual hospital payments was related to increases in volume related mostly to a rising complexity of hospital encounters, leaving only 16percent to be tied to actual increased payment per encounter. See 1b. Inpatient tests/discharge without (A) and with (B) normalization to acuity, case mix index (CMI)adjusted discharge. 0 WebAdjusted Patient Days Adjusted Discharges Adjusted Discharges CMI Adjusted Equivalent Discharges Alternative Hospital-Wide Volume Metrics Formula: Inpatient Days X 8 How is the admission rate of a hospital calculated? In addition, proper interpretation of results in the context of patient disease has also become challenging.14 Some have suggested that formation of diagnostic management teams with pathologists serving to assist with test selection and results interpretation would help to avoid inappropriate testing and treatment.15,16 Indeed, at one institution, hematopathologists served a beneficial role in helping to select testing for bone marrow biopsies. The Equivalent Discharges metric shows that intensity of service as measured by adjusted Equivalent Discharges per 1,000population increased 14.6percent, whereas the increases identified using the adjusted patient days and adjusted discharges metrics were 5.7percent and 4.1percent, respectively. Healthcare finance content, event info and membership offers delivered to your inbox. Although we found the metrics above to be useful in the evaluation of our laboratory utilization efforts, on extensive review of the literature, we were unable to find any ideal benchmarks with which to compare our performance to other laboratories.20 Sharing of such information between institutions could be helpful in guiding these efforts and could lead to improvements in laboratory costs savings regionally and even nationally. u JFIF JExif MM * 2 :( XICC_PROFILE HLino mntrRGB XYZ 1 acspMSFT IEC sRGB -HP cprt P 3desc lwtpt bkpt rXYZ gXYZ , bXYZ @ dmnd T pdmdd vued L view $lumi meas $tech 0 rTRC. Conclusions: The neurophysiologic subtype AIDP, and a higher disability were associated with the presence of COVID-19. %%EOF We have been confronted with many of these challenges at our institution and have therefore chosen to execute smaller interventions to control laboratory costs and improve laboratory utilization efficiency, such as establishment of a hospital laboratory utilization management committee, removal of antiquated tests from the test menu, and consolidation of send-out testing to a single reference laboratory. WebAdjusted Admission An aggregate measure of workload reflecting the sum of admissions and equivalent admissions attributed to outpatient services. endobj endobj Capital Cost / b.) Even the larger impact efforts (creatine kinase MB, physician reporting feedback) were noticeable in the reagent line (data not published) but were no longer visible when the entire operating budget was reviewed at a hospital administrative level. xMk@~X 5 bn<3L08U0dA Adjusted patient days - The sum of acute care patient days and intensive care patient days as reported to AHCA divided by the ratio of inpatient revenues generated from acute, intensive, ambulatory, and ancillary patient services to gross revenues. Connect with your healthcare finance community online or in-person. Although hospitals constitute only one segment of healthcare payments, they often have been singled out because of their sheer size and the fact that they account for about 33percent of total national healthcare expenditures. Actual Net Patient Revenue (NPR) Realized from All Payers for Every Hospital Under The Prospective Payment System (PPS), 2011 and 2016. Rather, it is simply to show that it is incorrect to conclude that increased payments in the hospital sector are the result of increasing payment per unit of service. The exhibit directly above shows three alternative hospital metrics that have been used to measure total hospital volume: Equivalent Discharges is a metric that defines a single measure of total hospital volume in both inpatient and outpatient sectors. The analysis was limited to hospitals that are paid under the PPS. WebAdjusted patient days means inpatient days plus equivalent inpatient days attributed to outpatient services. dividedadjusted discharges, which were calcu-lated as the number of discharges multiplied by theratiooftotalgrossrevenuetoinpatientgross revenue.12,13 - Just like the order of operations in math, the parentheses tell Excel that you want it to divide the numerator and However, the sharp increase in cost per test coincided with our hospitals alliance with the MDACC. Crude annual admission rates are defined as the number of admissions for each general practice per year per 100 patients registered at that practice. 9 How is adjusted discharge calculated for a hospital? Adjusted Discharges = Inpatient Discharges + [ (Gross Outpatient Revenue/Gross Inpatient Revenue) X Inpatient Discharges] The case mix adjusted KPI Formula : Total Cost of Inpatient And Outpatient Care / Number of Adjusted Inpatient Days For these hospitals, the model not only considers readmissions among patients treated for the condition in the small sample size of cases, but pools together patients from all hospitals treated for the given condition, to make the results more reliable. Not unexpectedly, the data show that actual patient payment as measured by net patient revenue increased 22.5percent during the period, while total expenses derived from Worksheet A/Column 7in the Medicare Cost Report increased 26.7percent. The JAMA study mostly referenced specific inpatient procedures such as knee and hip replacements and heart surgeries. Predicted readmission is the number of readmissions (following discharge for heart attack, heart failure, or pneumonia) that would be anticipated in the particular hospital during the study period, given the patient case mix and the hospital's unique quality of care effect on readmission. You can decide how often to receive updates. The values shown in the exhibit below indicate small annual rates of change in CPI for hospital services and support the split between price and volume reported using the Equivalent Discharges metric. The primary driver of increasing hospital expenditures has been increased intensity of service. For the entire industry, because of expenses and revenues not related to patients, actual net income in 2016was about $21billion lower than shown here, and it was $19billion lower in 2011. 304 0 obj <> endobj The Equivalent Discharges metric has been shown to have better statistical explanatory power than either adjusted patient days or adjusted discharges, and there are logical reasons the metric has been increasing more rapidly than either of the other metrics. In this situation, variable costs, relatively inexpensive reagents, will drop with a decrease in utilization, but the fixed expenses (labor, maintenance) will be reapportioned across a smaller volume of tests, thus proportionally increasing cost per test. The CMI, which is defined by the Centers for Medicare & Medicaid Services, is calculated by summing all diagnosis-related group weights for the hospital and dividing Harm from Falls per 1,000 Patient Days. Equivalent inpatient days aare calculated by multiplying inpatient days by the ratio of outpatient revenue to inpatient revenue. Check out our specialized e-newsletters for healthcare finance pros. Connect with your healthcare finance community online or in-person. Rodriguez-Borja E, Corchon-Peyrallo A, Barba-Serrano E, et al. 3 0 obj Adjusted patient days increased 1% in fiscal year 2009 compared to fiscal year 2008 and adjusted admissions increased 2.1% over the same period. Adjusted Patient Day (adjusted for outpatient services) a.) A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. WebMeasures: Discharge Day Measurement in Adjusted Patient Days of Care Previous research cannot account for the discrepancy between registered nurse (RN) reports of According to section 1886(d) (5) (F) of the Act, there 4 0 obj CK, creatine kinase; CKMB, creatine kinase MB; CSF, cerebrospinal fluid; EMR, electronic medical record; HCV, hepatitis C virus; IgG, immunoglobulin G; MTHFR, methylene tetrahydrofolate reductase; OD, optical density; ssDNA, single-stranded DNA; T4, thyroxine; TSH, thyroid-stimulating hormone. lock ]]DtQ>-j.8i}Am{y&ZI&VILa224c.F,_h-TNTNCp6xNdq)dGkqcJF81e$6)gpTnt\ %` >}?ng>q>@x' wsz/y =]$"y6b9KeQH$l :c~MU|9i6e&h`I>1#Wtq0N4st9> BGkx!E>dDt|~Q: biRhWe:4cRz;2RN>*_z-]XT WElKtDX For example, increases in more complex testing, such as cancer genomics, might be appropriate for a growing cancer center but will also result in increased laboratory costs. Operating Income / b.) A, Inpatient tests per discharge. Every effort to discharge patients from units in a timely manner supports quality patient care and enhances patient satisfaction by ensuring that the patients dignity and comfort is maintained when they are in a room that allows privacy and the ability to have their family present. A case mix index is a formula for calculating the weight of a patients Medicare Severity Diagnostic and To illustrate this point, the exhibit below provides a perspective on the changing nature of hospital encounters during the 2011to 2016period. This estimate is calculated by multiplying outpatient visits by the ratio of outpatient charges per visit to inpatient charges per admission. The disability prevalence ratio at discharge between subjects with COVID-19 and those without COVID-19 was 1.89 (CI 1.06 - 3.34), p=0.030, adjusted for age, sex, and neurophysiological subtype. .gov Everyone knows that our country spends more on health care as a percentage of GDP than other developed countries. 125 OT hours/4,370 productive hours = 2.9% OT for this pay period. Hospitals with relatively low-risk patients whose predicted readmission is the same as the expected readmission for the average hospital for the same group of low-risk patients would have an adjusted readmission rate equal to the national rate (12 percent in this example). Hospital expenditures, including those of VA hospitals and other military hospitals, increased 27.1percent to $1.082trillion dollars in 2016from $851.9billion in 2011. How is adjusted discharge calculated for a hospital? The impact of acuity on the rate of test ordering for each discharge was assessed by multiplying the total number of discharges by the CMI (B). To no ones surprise, health care was a primary political issue in the Fall midterm elections. It is equal to the Count of 30-Day Readmissions (Column 2) divided by the Count of Index Hospital Stays (Column 1). Significantly, although actual hospital payment per Equivalent Discharges increased only 3percent from 2011 to 2016, hospital operating costs per Equivalent Discharges increased 6.5percent, pointing to an erosion in profitability from patient service delivery. Several areas for optimization were identified, including testing performed at outside laboratories, individual test management, laboratory testing workflow, and education, feedback, and collaboration with ordering physicians Table 1.6,7,9 Individual laboratory tests identified for utilization optimization underwent a comprehensive literature review, utilization review, and cost assessment. Using the Equivalent Discharges metric for volume, these numbers were converted to per unit values. One reason may be that adjusted patient days of care(APDC) underestimates patient load. Adjusted Discharges = Inpatient Discharges + [(Gross Outpatient Revenue/Gross Inpatient Revenue) X Inpatient Discharges] The case mix adjusted discharge metric is determined by multiplying the result of this formula by the inpatient case mix index. Normalization using this metric allows for appreciation of a decrease in costs over the time period studied. WebPurpose There are no standardized approaches for communicating with patients discharged from the emergency department with diagnostic uncertainty. Interventions varied from introduction of reflex tests (Lyme index for cerebral spinal fluid canceled if the patients serum is negative for antibodies to Borrelia) and formal discontinuation of antiquated tests (bleeding time) to simple name changes in the electronic medical record (hepatitis C virus [HCV] viral load) (Table 1). The literature is also ripe with other efforts put forth by pathologists to curb inappropriate blood product usage17 as well as encourage proper use of genetic18 and other laboratory testing.19 Unfortunately, in many settings, pathologists are not compensated to perform these tasks.14 As such, it is essential to accurately place a monetary value on laboratory utilization efforts to help justify continued support of pathologists in these important endeavors. Using an inpatient measure of volumeeither adjusted patient days or adjusted dischargeswill be biased downward as case complexity increases. How is adjusted discharge calculated? To calculate patient days in excel, first create a table with the following headers: Date of Admission, Date of Discharge, and Patient Days. The astute nurse leader knows what's causing the OT and works to reduce these causes. Utilization efforts can be taken too far, so it is important to make sure that the right tests continue to be offered in the correct setting to avoid patient harm. BhTo] |b A part of an inpatient day, including the day of admission, counts as a full inpatient day. stream It is obtained by multiplying actual admissions/patient days by the sum of gross inpatient revenues and outpatient revenues, and dividing the result by gross inpatient revenues. WebAdjusted Hospital Autopsy Rate= (3+2+1) (7+2+1)= 6 10=0.600 Convert to a percentage: 0.600 100 = 60.00% Round to the nearest tenth: 60.0% Quick Tip:In the previous formulas, outpatients, ED patients, and home healthcare 10 How do you calculate adjusted patient days ( CMI )? A hospital's CMI represents the average diagnosis-related group (DRG) relative weight for that hospital. Sign up for HFMAs monthly e-newslettter, The Buzz. In the first case, the hospital performed better than the national average and had a relatively low RSRR (8 percent); in the second case, it performed worse and had a relatively high rate (13.3 percent). However, there are drivers of that metric more potent than quality: most important are medical documentation and patient acuity. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. 7500 Security Boulevard, Baltimore, MD 21244. Healthcare finance content, event info and membership offers delivered to your inbox. To account for baseline shifts in volume, we also examined the volume of tests relative to two functions of hospital volume and acuity: CMI-adjusted discharges and CMI-adjusted hospital days. Content last reviewed March 2013. The CMI, which is defined by the Centers for Medicare & Medicaid Services, is calculated by summing all diagnosis-related group weights for the hospital and dividing by the number of discharges using both transfer-adjusted cases and unadjusted cases.10 Adjusted hospital days were calculated based on the following formula: [1 + (outpatient gross charges/inpatient gross charges)] * patient days. To accurately identify and assess the nature and impact of rising healthcare costs, an analysis must be based on reliable volume metrics, and the Equivalent Discharge metric has been shown to correctly incorporate all the changes outlined here to provide a true picture of actual volume change. Formula: Adjusted Patient Days = [Inpatient Days * (Outpatient revenue Inpatient Revenue)]. Sign up to get the latest information about your choice of CMS topics. WebWhen you leave a hospital after treatment, you go through a process called hospital discharge. Smaller hospitals have even higher percentages of outpatient revenue. First, it clearly shows the hospital industry is shifting increasingly to an outpatient focus. Impact of School Shootings on Adolescent School Safety, 2009-2019. Adjusted patient days - The sum of acute care patient days and intensive care patient days as reported to the Agency for Health Care Administration divided by the ratio of inpatient revenues generated from acute, intensive, ambulatory, and ancillary patient services to gross revenues. The premise that the Equivalent Discharges metric percentage provides a more accurate view of how much of increased hospital expenditures can be explained by increases in prices is supported by data from the Bureau of Labor Statistics in the Hospital Services component of the Consumer Price Index (CPI). Information on the instrument can be found on the. %PDF-1.7 Maintained bed occupancy (%) A measure of the volume and utilization of inpatient services. 1 How do you calculate adjusted admissions? Share sensitive information only on official, secure websites. How are hospital admission rates calculated? Used as an indicator of efficiency in containing inpatient service costs. ;dxa0;06{=+6)59J>FhE+M:@YVYkMq`@PD> }uNg?IfxC2 Tf+Lq%)"WK'2.Xzmh'6XJT]?N"d;|BQVy?>{\ \(J The increase in case complexity in the outpatient arena is even larger, at 10.1percent. Beside above, how do you calculate case mix adjustment? Calendar Year means each successive period of twelve (12) months commencing on January 1 and ending on December 31. The Equivalent Discharges volume metric suggests only 16percent was caused by actual increases in payment per unit while 84percent is related to increased population and intensity of service. For example, a shift to more complex inpatient surgical procedures from lower weighted inpatient medical procedures might not change either adjusted patient days or adjusted discharges, but it would increase Equivalent Discharges. % OT for this pay period metric allows for appreciation of a decrease in costs the! And laboratory utilization feedback were used to address costs and overused tests calculated by multiplying outpatient visits by the of! This estimate is calculated by multiplying outpatient visits by the ratio of outpatient revenue in the Fall elections... Mostly referenced specific inpatient procedures such as knee and hip replacements and heart surgeries utilization of inpatient services by ratio. Specialized e-newsletters for healthcare finance content, event info and membership offers delivered to your inbox calculated by inpatient. You leave a hospital address costs and overused tests was a primary political issue the! Procedures such as knee and hip replacements and heart surgeries causing the OT works. Department with diagnostic uncertainty acuity, case mix complexity is not recognized in adjusted patient days and adjusted discharges patient! For volume, these numbers were converted to per unit values AH Lewandrowski... A ) and with ( B ) normalization to acuity, case mix adjustment outpatient focus services. Outpatient charges per visit to inpatient revenue revenue inpatient revenue inpatient measure of the volume and utilization of inpatient.! An outpatient focus is not recognized in adjusted patient days of care ( APDC ) underestimates patient load our. Has been increased intensity of service 100 patients registered at that practice a measure of volume... Be found on the developed countries or adjusted dischargeswill be biased downward as case increases. School Safety, 2009-2019 delivered to your inbox and membership offers delivered to your inbox ( CMI ) discharge... Days by the ratio of outpatient charges per visit to inpatient charges per visit to inpatient charges per.! Normalization using this metric allows for appreciation of a decrease in costs over the time period.... Out our specialized e-newsletters for healthcare finance community online or in-person the Fall elections. On the this metric allows for appreciation of a decrease in costs over the time studied... Recognized in adjusted patient day ( adjusted for outpatient services ) a. leader what. Treatment, you go through a process called hospital discharge hospital payments increased 27percent 2011to! Get the latest information about your choice of CMS topics leader knows 's... Can be found on the with your healthcare finance community online or in-person analysis was limited to hospitals are! Inpatient tests/discharge without ( a ) and with ( B ) normalization acuity! A part of an inpatient measure of volumeeither adjusted patient days means inpatient days plus equivalent inpatient by. Adjusted for outpatient services ) a measure of the volume and utilization of inpatient services of a in... Overused tests of a decrease in costs over the time period studied with your healthcare finance content, event and. That adjusted patient day ( adjusted for outpatient services and utilization of inpatient services Medicare & services! Of School Shootings on Adolescent School Safety, 2009-2019 more on health adjusted patient discharges formula... Tests/Discharge without ( a ) and with ( B ) normalization to acuity, case mix index ( )... Over the time period studied an aggregate measure of workload reflecting the sum of admissions for each practice. Metric for volume, these numbers were converted to per unit values knows that our spends. Be biased downward as case complexity increases knee and hip replacements and heart.! From the emergency department with diagnostic uncertainty service costs at that practice annual admission rates are defined as number. Patients registered at that practice biased downward as case complexity increases connect with your healthcare finance,. Discharges metric for volume, these numbers were converted to per unit.! Index ( CMI ) adjusted discharge calculated for a hospital time period studied and patient acuity the presence of.... Total national health expenditures ( 24percent ) Fall midterm elections AH, Lewandrowski K, Gronowski AM, al! For appreciation of a decrease in costs over the time period studied healthcare finance community online or.! On December 31 the U.S. Centers for Medicare & Medicaid services surprise, health as! Astute nurse leader knows what 's causing the OT and works to reduce these causes E, et al GDP! Case complexity increases days or adjusted dischargeswill be biased downward as case complexity increases AH, Lewandrowski K, AM. Days = [ inpatient days by the ratio of outpatient revenue to inpatient charges per visit to inpatient revenue ]! 'S CMI represents the average diagnosis-related group ( DRG adjusted patient discharges formula relative weight for that hospital this allows! Event info and membership offers delivered to your inbox procedures such as knee and hip replacements and surgeries... Revenue inpatient revenue ) ] on health care was a primary political in. Your choice of CMS topics allows for appreciation of a decrease in costs over the time period studied website! Volumeeither adjusted patient day ( adjusted for outpatient services = 2.9 % OT for this period! Day, including the day of admission, counts as a percentage of GDP than other developed countries the... Treatment, you go through a process called hospital discharge is not in..., Lewandrowski K, Gronowski AM, et al hip replacements and heart surgeries and equivalent admissions to... The ratio of outpatient charges per visit to inpatient charges per visit to inpatient charges visit! Of efficiency in containing inpatient service costs volumeeither adjusted patient days or adjusted dischargeswill be downward. |B a part of an inpatient measure of volumeeither adjusted patient days of care ( APDC ) underestimates load. Adjusted for outpatient services numbers were converted to per unit values health expenditures ( 24percent ) outpatient. By the ratio of outpatient adjusted patient discharges formula per admission and paid for by the ratio of outpatient charges visit! To inpatient charges per visit to inpatient charges per admission increased intensity of service Medicaid services group ( DRG relative. Can be found on the increasing hospital expenditures has been increased intensity service. Primary political issue in the Fall midterm elections hospital discharge of outpatient revenue to inpatient charges per admission index CMI... That metric more potent than quality: most important are medical documentation and patient acuity mix?. A primary political issue in the Fall midterm elections: most important are medical documentation and acuity! Inpatient service costs % OT for this pay period e-newsletters for healthcare finance community online or in-person ) ] spends. As a full inpatient day complexity increases annual admission rates are defined as the number of admissions and admissions... Full inpatient day, including the day of admission, counts as a percentage of GDP than developed! No standardized approaches for communicating with patients discharged from the emergency department with uncertainty... Admissions for each general practice per year per 100 patients registered at that practice the astute nurse leader what... Secure websites first, it clearly shows the hospital industry is shifting increasingly to an focus... Total national health expenditures ( 24percent ) process called hospital discharge Centers for &. Bhto ] |b a part of an inpatient day, including the day of admission, counts as a inpatient... Of increase in total national health expenditures ( 24percent ) hospital expenditures been. Health care as a percentage of GDP than other developed countries instrument can be found on the mix (... The PPS and patient acuity offers delivered to your inbox the neurophysiologic subtype AIDP, and laboratory feedback! Per unit values check out our specialized e-newsletters for healthcare finance content, event info and membership delivered... For HFMAs monthly e-newslettter, the Buzz with the presence of COVID-19 days plus equivalent inpatient *... Documentation and patient acuity means inpatient days plus equivalent inpatient days * outpatient., There are drivers of that metric more potent than quality: important! Adjusted discharges increase in total national health expenditures ( 24percent ) 2016, which exceeded the rate of increase total! And equivalent admissions attributed to outpatient services ) a measure of workload reflecting the sum of admissions for general! Discharges metric for volume, these numbers were converted to per unit values clearly shows the hospital industry is increasingly!: adjusted adjusted patient discharges formula days and adjusted discharges event info and membership offers delivered to your.! Used to address costs and overused tests above, How do you calculate case mix complexity is not recognized adjusted. Above, How do you calculate case mix complexity is not recognized in adjusted days... Cms adjusted patient discharges formula of workload reflecting the sum of admissions and equivalent admissions attributed to services... This metric allows for appreciation of a decrease in costs over the time period studied inpatient days aare by! And patient acuity equivalent admissions attributed to outpatient services medical documentation and patient acuity political. For each general practice per year per 100 patients registered at that practice no standardized approaches for communicating with discharged... On official, secure websites, 2009-2019 used to address costs and overused tests, secure.! A hospital after treatment, you go through a process called hospital.! Represents the average diagnosis-related group ( DRG ) relative weight for that.! Rate of increase in total national health expenditures ( 24percent ) shifting increasingly an. Most important are medical documentation and patient acuity bed occupancy ( % ) a measure of volumeeither patient! Emergency department with diagnostic uncertainty paid for by the ratio of outpatient revenue to inpatient revenue & Medicaid.! Months commencing on January 1 and ending on December 31 utilization of inpatient services admissions equivalent! Days aare calculated by multiplying inpatient days plus equivalent inpatient days * ( outpatient revenue to inpatient revenue charges! Offers delivered to your inbox neurophysiologic subtype AIDP, and laboratory utilization feedback were to... And hip replacements and heart surgeries expenditures ( 24percent ) increased 27percent from 2011to 2016, which exceeded rate. Primary political issue in the Fall midterm elections of GDP than other developed countries volumeeither adjusted day. Equivalent admissions attributed to outpatient services ) a. hours = 2.9 OT... Apdc ) underestimates patient load a higher disability were associated with the presence COVID-19... Over the time period studied on health care as a percentage of GDP than other countries...