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Cao Z, Liu X, Wang X, Guo M, Guan Z. Impacts of DRG-Based Prepayment Reform on the Cost and Quality of Patients with Neurologic Disorders: Evidence from a Quasi-Experimental Analysis in Beijing, China. Risk Manag Healthc Policy 2024; 17:1547-1560. [PMID: 38894816 PMCID: PMC11182875 DOI: 10.2147/rmhp.s458005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 05/10/2024] [Indexed: 06/21/2024] Open
Abstract
Purpose As one of the pioneering pilot cities in China's extensive Diagnosis Related Groups (DRG) -based prepayment reform, Beijing is leading a comprehensive overhaul of the prepayment system, encompassing hospitals of varying affiliations and tiers. This systematic transformation is rooted in extensive patient group data, with the commencement of actual payments on March 15, 2022. This study aims to evaluate the effectiveness of DRG payment reform by examining how it affects the cost, volume, and utilization of care for patients with neurological disorders. Patients and Methods Utilizing the exogenous shock resulting from the implementation of the DRG-based prepayment system, we adopted the Difference-in-Differences (DID) approach to discern changes in outcome variables among DRG payment cases, in comparison to control cases, both before and following the enactment of the DRG policy. The analytical dataset was derived from patients diagnosed with neurological disorders across all hospitals in Beijing that underwent the DRG-based prepayment reform. Strict data inclusion and exclusion criteria, including reasonableness tests, were applied, defining the pre-reform timeframe as March 15th through October 31st, 2021, and the post-reform timeframe as the corresponding period in 2022. The extensive dataset encompassed 53 hospitals and encompassed hundreds of thousands of cases. Results The implementation of DRG-based prepayment resulted in a substantial 12.6% decrease in total costs per case and a reduction of 0.96 days in length of stay. Additionally, the reform was correlated with significant reductions in overall in-hospital mortality and readmission rates. Surprisingly, the study unearthed unintended consequences, including a significant reduction in the proportion of inpatient cases classified as surgical patients and the Case Mix Index (CMI), indicating potential strategic adjustments by providers in response to the introduction of DRG payments. Conclusion The DRG payment reform demonstrates substantial effects in restraining cost escalation and enhancing quality. Nevertheless, caution must be exercised to mitigate potential issues such as patient selection bias and upcoding.
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Affiliation(s)
- Zhen Cao
- School of Public Health, Capital Medical University, Beijing, People’s Republic of China
| | - Xiaoyu Liu
- School of Statistics, Capital University of Economics and Business, Beijing, People’s Republic of China
| | - Xiangzhen Wang
- School of Public Health, Peking University Health Science Center, Beijing, People’s Republic of China
| | - Moning Guo
- Beijing Municipal Health Big Data and Policy Research Center, Beijing, People’s Republic of China
| | - Zhongjun Guan
- School of Public Health, Capital Medical University, Beijing, People’s Republic of China
- Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
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Chen YJ, Zhang XY, Tang X, Yan JQ, Qian MC, Ying XH. How do inpatients' costs, length of stay, and quality of care vary across age groups after a new case-based payment reform in China? An interrupted time series analysis. BMC Health Serv Res 2023; 23:160. [PMID: 36793088 PMCID: PMC9933283 DOI: 10.1186/s12913-023-09109-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 01/25/2023] [Indexed: 02/17/2023] Open
Abstract
CONTEXT A patient classification-based payment system called diagnosis-intervention packet (DIP) was piloted in a large city in southeast China in 2018. OBJECTIVE This study evaluates the impact of DIP payment reform on total costs, out-of-pocket (OOP) payments, length of stay (LOS), and quality of care in hospitalised patients of different age. METHODS An interrupted time series model was employed to examine the monthly trend changes of outcome variables before and after the DIP reform in adult patients, who were stratified into a younger (18-64 years) and an older group (≥ 65 years), further stratified into young-old (65-79 years) and oldest-old (≥ 80 years) groups. RESULTS The adjusted monthly trend of costs per case significantly increased in the older adults (0.5%, P = 0.002) and oldest-old group (0.6%, P = 0.015). The adjusted monthly trend of average LOS decreased in the younger and young-old groups (monthly slope change: -0.058 days, P = 0.035; -0.025 days, P = 0.024, respectively), and increased in the oldest-old group (monthly slope change: 0.107 days, P = 0.030) significantly. The changes of adjusted monthly trends of in-hospital mortality rate were not significant in all age groups. CONCLUSION Implementation of the DIP payment reform associated with increase in total costs per case in the older and oldest-old groups, and reduction in LOS in the younger and young-old groups without deteriorating quality of care.
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Affiliation(s)
- Ya-jing Chen
- grid.8547.e0000 0001 0125 2443School of Public Health, Fudan University, Shanghai, China
| | - Xin-yu Zhang
- grid.8547.e0000 0001 0125 2443School of Public Health, Fudan University, Shanghai, China
| | - Xue Tang
- grid.8547.e0000 0001 0125 2443School of Public Health, Fudan University, Shanghai, China
| | - Jia-qi Yan
- grid.8547.e0000 0001 0125 2443School of Public Health, Fudan University, Shanghai, China
| | - Meng-cen Qian
- grid.8547.e0000 0001 0125 2443School of Public Health, Fudan University, Shanghai, China ,grid.8547.e0000 0001 0125 2443Key Laboratory of Health Technology Assessment (Fudan University), Ministry of Health, Fudan University, 130 Dongan Road, Shanghai, China
| | - Xiao-hua Ying
- grid.8547.e0000 0001 0125 2443School of Public Health, Fudan University, Shanghai, China ,grid.8547.e0000 0001 0125 2443Key Laboratory of Health Technology Assessment (Fudan University), Ministry of Health, Fudan University, 130 Dongan Road, Shanghai, China
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Aktas P. Physician perspectives on the implications of the diagnosis-related groups for medical practice in Turkey: A qualitative study. Int J Health Plann Manage 2022; 37:1769-1780. [PMID: 35180321 PMCID: PMC9305241 DOI: 10.1002/hpm.3445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 01/06/2022] [Accepted: 02/08/2022] [Indexed: 11/26/2022] Open
Abstract
Hospital reimbursement models might have unintended consequences for medical practice. In Turkey, a mixed reimbursement scheme, based on the diagnosis‐related group (DRG) model and global budget, was gradually introduced as part of the country's 2003 healthcare reforms. This article examines the impacts of the DRG model on medical practice in Turkey, as perceived by physicians working in public and private hospitals. This study draws on an analysis of 14 interviews with physicians. The findings reveal that the implementation of the DRG has transformed medical practice into a process of cost‐benefit optimisation which involves balancing the income and expenses of hospitals against patients' medical needs. To mitigate the negative effects of the DRG, the current model may need to be reformed, particularly to grant exemptions from the standard reimbursement structure for patients who are experiencing complications and/or multiple health conditions. The diagnosis‐related group has transformed medical practice in Turkey into a process of optimisation. Physicians are responsible for balancing hospital budgets against patients' medical needs under the current reimbursement model. Limited reimbursements for most of healthcare services hinder effective medical practice. Physicians agree upon the need to increase hospital reimbursement levels by the Social Security Institution.
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Affiliation(s)
- Puren Aktas
- Social Policy ForumBogazici UniversityIstanbulTurkey
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Spiess AAF, Skempes D, Bickenbach J, Stucki G. Exploration of current challenges in rehabilitation from the perspective of healthcare professionals: Switzerland as a case in point. Health Policy 2021; 126:173-182. [PMID: 34625281 DOI: 10.1016/j.healthpol.2021.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 09/09/2021] [Accepted: 09/23/2021] [Indexed: 12/11/2022]
Abstract
Rehabilitation is a health strategy with the potential to mitigate the negative health consequences of population ageing and the rise of noncommunicable diseases. Literature indicates that even in high-income countries rehabilitation services can be improved. The purpose of this study is to engage rehabilitation professionals in Switzerland in identifying and prioritizing current challenges in the development and delivery of rehabilitation services. We conducted a qualitative study consisting of interviews with key informants and a stakeholder consultation. Thirteen interviews were conducted and analysed using inductive thematic analysis. Identified challenges were refined, extended, and prioritized through multi-voting in a workshop attended by a wide range of rehabilitation professional organizations. Final results were subject to further analysis and member checking. We identified nineteen challenges, of which eight were viewed as highly important. Results suggest the need to revise the financing system for rehabilitation services, highlighted a poor integration of rehabilitation in primary care, a lack of academic rehabilitation training, and insufficient funding for research. Finally, we identified a perceived lack of awareness for rehabilitation among policy-makers and the public. This study provides a unique perspective on challenges in rehabilitation practice and policy and offers an opportunity for professionals, policy-makers, and other stakeholders, to influence and guide the rehabilitation service agenda both in Switzerland and in terms of mutual learning also in other countries.
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Affiliation(s)
- Adrian Andrea Flavio Spiess
- Department of Health Sciences and Medicine, University of Lucerne, Frohburgstrasse 3, 6002 Lucerne, Switzerland.
| | - Dimitrios Skempes
- Department of Health Sciences and Medicine, University of Lucerne, Frohburgstrasse 3, 6002 Lucerne, Switzerland; Swiss Paraplegic Research (SPF), Guido A. Zaech Strasse 4, 6207 Nottwil, Switzerland..
| | - Jerome Bickenbach
- Department of Health Sciences and Medicine, University of Lucerne, Frohburgstrasse 3, 6002 Lucerne, Switzerland; Swiss Paraplegic Research (SPF), Guido A. Zaech Strasse 4, 6207 Nottwil, Switzerland..
| | - Gerold Stucki
- Department of Health Sciences and Medicine, University of Lucerne, Frohburgstrasse 3, 6002 Lucerne, Switzerland; Swiss Paraplegic Research (SPF), Guido A. Zaech Strasse 4, 6207 Nottwil, Switzerland..
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Al-Khalil O, Valeri F, Senn O, Rosemann T, Di Gangi S. Effects of a DRG-based hospital reimbursement on the health care utilization and costs in Swiss primary care: A retrospective "quasi-experimental" analysis. PLoS One 2020; 15:e0241179. [PMID: 33108373 PMCID: PMC7591068 DOI: 10.1371/journal.pone.0241179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 10/12/2020] [Indexed: 11/18/2022] Open
Abstract
Introduction In Switzerland, a nationwide Swiss Diagnosis related Groups (Swiss DRG) system for hospital reimbursement was introduced in 2012. However, the impact of DRG systems on primary care is still unclear with respect to number of consultations and costs. The aim of this study was to investigate the effect of the implementation of DRG on costs and volumes in the primary care sector, on a nationwide basis in Switzerland. Methods The study retrospectively analysed yearly data, from 2008 to 2014, of almost 60 Swiss health insurers that covered almost all Swiss general practitioners, with a total number of patients which represented approximately 76% of the Swiss population. GP consultations, total numbers and rates, and the relative costs reimbursed (TARMED tariff values) in the Swiss federal states, cantons, which already introduced a DRG-like system before 2012 (AP-DRG), were compared to the GP consultations and costs reimbursed in the other cantons (DRG-naive). Regression discontinuity design analysis and mixed regression models, at cantonal level, were performed to evaluate the effect of the nationwide implementation of the Swiss DRG on health care demand and costs in the primary care setting. Change in outcome level and yearly trend pattern difference between groups (AP-DRG vs. DRG-naive) were examined. Results Overall, the total number of GP consultations and the relative TARMED values increased from 2008 to 2014. In the DRG naive, 15 cantons: in 2008, the number of GP consultations were 13,114,126, with a TARMED value of 1,194,957,157 CHF, and in 2014, the GP consultation were 13,752,511, with a TARMED value of 1,513,861,260 CHF. In the AP-DRG group, 11 cantons, the total number of GP consultations increased from 8,787,646, in 2008, to 9,347,168 in 2014 and the TARMED value increased from 896,673,657 CHF in 2008, to 1,100,203,508 CHF in 2014. The yearly trend pattern of GP consultations and TARMED values, in the AP-DRG group, were not significantly different from the respective trends in the DRG- naive and, overall, no significant change was detected in consultations and costs trends before and after 2012. Discussion/Conclusion This study found no evidence of any effect of the introduction of the SwissDRG on the yearly trend of primary care consultations and costs. Nevertheless, potential negative impacts on vulnerable patients, as chronically ill patients, could not be excluded and further investigation is required.
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Affiliation(s)
- Omar Al-Khalil
- Institute of Primary Care, University and University Hospital of Zurich, Zurich, Switzerland
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Switzerland
- * E-mail:
| | - Fabio Valeri
- Institute of Primary Care, University and University Hospital of Zurich, Zurich, Switzerland
| | - Oliver Senn
- Institute of Primary Care, University and University Hospital of Zurich, Zurich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University and University Hospital of Zurich, Zurich, Switzerland
| | - Stefania Di Gangi
- Institute of Primary Care, University and University Hospital of Zurich, Zurich, Switzerland
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Kollbrunner L, Rost M, Koné I, Zimmermann B, Padrutt Y, Wangmo T, Elger B. Acute and transitional care or rehabilitation? Retrospective analysis of discharge planning from a municipal hospital in Switzerland. BMC Health Serv Res 2020; 20:712. [PMID: 32746810 PMCID: PMC7397668 DOI: 10.1186/s12913-020-05547-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 07/15/2020] [Indexed: 11/27/2022] Open
Abstract
Background Due to rising health care costs, in 2012 Switzerland introduced SwissDRG, a reimbursement system for hospitals based on lump sum per case. To circumvent possible negative consequences like reduction in length of stay, acute and transitional care (ATC) was anchored into the law (Federal act on health insurance) in 2011. ATC as a discharge option is applicable to patients who physicians deem will not fulfill rehabilitation criteria, but are unable to return home and are in need of temporary professional nursing care. ATC is associated with higher out of pocket costs to the patient than rehabilitation. Since social service workers are responsible for organizing discharge for patients with ongoing care needs after hospitalization, the aim of this study was to investigate how social service workers manage patient discharge in light of the new discharge option ATC. Methods Data was collected from 423 medical records of inpatients from Zurich’s municipal hospital, Triemli, discharged to ATC or rehabilitation, in 2016. We compared the two groups using inferential statistics and qualitatively analyzed written statements from social service workers. Results Our results showed that patients discharged to rehabilitation had a higher total number of discussions, but a shorter duration of discussions. Patients discharged to rehabilitation faced more delays, mainly due to unavailability of beds in rehabilitation centers. Conflicts concerning discharge arose mainly because of costs, discharge placement and too early discharge. Conclusions Our findings demonstrate how important social service workers are in providing information to patients about different discharge options. The newness of SwissDRG and ATC is still likely to cause longer discussion times and, consequently, more workload for social service workers. Only a small fraction of patients disagreed with their place of discharge, mostly due to financial reasons.
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Affiliation(s)
- Lara Kollbrunner
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland.
| | - Michael Rost
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland
| | - Insa Koné
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland
| | - Bettina Zimmermann
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland
| | - Yvonne Padrutt
- Institute of legal science, University of Zurich, Treichlerstrasse 10, 8032 Zürich, Switzerland
| | - Tenzin Wangmo
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland
| | - Bernice Elger
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland.,Center for legal medicine, University of Geneva, Rue Michel-Servet 1, 1211 Geneva, Switzerland
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Chien LC, Chou YJ, Huang YC, Shen YJ, Huang N. Reducing low value services in surgical inpatients in Taiwan: Does diagnosis-related group payment work? Health Policy 2020; 124:89-96. [DOI: 10.1016/j.healthpol.2019.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 08/20/2019] [Accepted: 10/12/2019] [Indexed: 01/26/2023]
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Wangmo T, Padrutt Y, Koné I, Gächter T, Elger BS, Leu A. Practicality of Acute and Transitional Care and its consequences in the era of SwissDRG: a focus group study. BMC Health Serv Res 2019; 19:374. [PMID: 31196075 PMCID: PMC6567569 DOI: 10.1186/s12913-019-4220-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 06/05/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Switzerland recently introduced Acute and Transitional Care (ATC) as a new financing option and a preventive measure to mitigate potential side effects of Swiss Diagnosis Related Group (SwissDRG). The goal of ATC was to support patients who after acute treatment at a hospital require temporary increased professional care. However, evidence is lacking as to the practicality of ATC. METHODS Using qualitative focus group methodology, we sought to understand the implementation and use of ATC. A purposive sample of forty-two professionals from five Swiss cantons participated in this study. We used a descriptive thematic approach to analyse the data. RESULTS Our findings first reveal that ATC's implementation differs in the five cantons (i.e. federal states). In two cantons, only ambulatory variant of ATC is used; in one canton only stationary ATC has been created, and two cantons had both ambulatory and stationary ATC but preferred the latter. Second, there are intrinsic practical challenges associated with ATC, which include physicians' lack of familiarity with ATC and its regulatory limitations. Finally, participants felt that due to shorter hospital stays because of SwissDRG, premature discharge of patients with complex care needs to stationary ATC takes place. This development does not fit the nursing home concept of care tailored to long-term patients. CONCLUSION This empirical study underscores that there is a strong need to improve ATC so that it is uniformly implemented throughout the country and its application is streamlined. In light of the newness of ATC as well as SwissDRG, their impact on the quality of care received by patients is yet to be fully understood. Empirical evidence is necessary to improve these two measures.
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Affiliation(s)
- Tenzin Wangmo
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland.
| | - Yvonne Padrutt
- Faculty of Law, University of Zurich, Zurich, Switzerland
| | - Insa Koné
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland
| | - Thomas Gächter
- Faculty of Law, University of Zurich, Zurich, Switzerland
| | - Bernice S Elger
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland.,Center for Legal Medicine, University of Geneva, Geneva, Switzerland
| | - Agnes Leu
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland.,Department Health Sciences, Kalaidos University of Applied Sciences, Zurich, Switzerland
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Koné I, Maria Zimmermann B, Nordström K, Simone Elger B, Wangmo T. A scoping review of empirical evidence on the impacts of the DRG introduction in Germany and Switzerland. Int J Health Plann Manage 2018; 34:56-70. [PMID: 30426573 DOI: 10.1002/hpm.2669] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/24/2018] [Accepted: 08/27/2018] [Indexed: 11/09/2022] Open
Abstract
CONTEXT Germany and Switzerland have introduced diagnosis-related groups (DRGs) for hospital reimbursement. This scoping review aims to evaluate if empirical evidence exists on the effect of the DRG introduction. METHODS Medline via PubMed, Embase (Elsevier), CINAHL, PsychINFO, and Psyndex were systematically screened for studies from 2003 onwards using keywords-DRG, prospective payment system, and lump sum-in English, German, and French. Abstracts were screened for alignment with our inclusion criteria and classified as editorial/commentary, review, or empirical study. The full-text extraction included data on country, study design, collected data, study population, specialty, comparison group, and outcome measures. RESULTS Our literature search yielded 1944 references, of which 1405 references were included in the abstract screening after removal of duplicates. 135 articles were relevant to DRG, including 94 editorials/comments/reviews and 41 empirical articles from 36 different samples. The most frequently used outcome parameters were length of stay (12), reimbursement/cost (9), and case numbers (9). CONCLUSIONS Only a minority of identified articles (30.4%; 41 of 135) presented empirical data. This indicates that discussion on the topic is not totally evidence-based. The only common trend was a decrease in length of stay.
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Affiliation(s)
- Insa Koné
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | | | - Karin Nordström
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland.,Theological Ethics and Social Ethics, University of Lucerne, Lucerne, Switzerland
| | | | - Tenzin Wangmo
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
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Quentin W, Busse R. The strongly decentralized Swiss health system achieves good results: Past research has addressed persisting challenges - but more is encouraged. Health Policy 2018; 122:565-567. [PMID: 29935709 DOI: 10.1016/j.healthpol.2018.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Wilm Quentin
- Technische Universität Berlin, Fachgebiet Management im Gesundheitswesen, Straße des 17. Juni 135, Sekr. H80, 10623, Berlin, Germany
| | - Reinhard Busse
- Technische Universität Berlin, Fachgebiet Management im Gesundheitswesen, Straße des 17. Juni 135, Sekr. H80, 10623, Berlin, Germany.
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