1
|
Quentin W, Stephani V, Berenson RA, Bilde L, Grasic K, Sikkut R, Touré M, Geissler A. How Denmark, England, Estonia, France, Germany, and the USA Pay for Variable, Specialized and Low Volume Care: A Cross-country Comparison of In-patient Payment Systems. Int J Health Policy Manag 2022; 11:2940-2950. [PMID: 35569000 PMCID: PMC10105175 DOI: 10.34172/ijhpm.2022.6536] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 04/15/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Diagnosis-related group (DRG)-based hospital payment can potentially be inadequately low (or high) for highly variable, highly specialized, and/or low volume care. DRG-based payment can be combined with other payment mechanisms to avoid unintended consequences of inadequate payment. The aim of this study was to analyze these other payment mechanisms for acute inpatient care across six countries (Germany, Denmark, England, Estonia, France, the United States [Medicare]). METHODS Information was collected about elements excluded from DRG-based payment, the rationale for exclusions, and payment mechanisms complementing DRG-based payment. A conceptual framework was developed to systematically describe, visualise and compare payment mechanisms across countries. RESULTS Results show that the complexity of exclusion mechanisms and associated additional payment components differ across countries. England and Germany use many different additional mechanisms, while there are only few exceptions from DRG-based payment in the Medicare program in the United States. Certain areas of care are almost always excluded (eg, certain areas of cancer care or specialized pediatrics). Denmark and England use exclusion mechanisms to steer service provision for highly complex patients to specialized providers. CONCLUSION Implications for researchers and policy-makers include: (1) certain areas of care might be better excluded from DRG-based payment; (2) exclusions may be used to incentivize the concentration of highly specialized care at specialized institutions (as in Denmark or England); (3) researchers may apply our analytical framework to better understand the specific design features of DRG-based payment systems.
Collapse
Affiliation(s)
- Wilm Quentin
- Department of Health Care Management, Technische Universität Berlin, Berlin, Germany
- European Observatory on Health Systems and Policies, Brussels, Belgium
| | | | | | - Lone Bilde
- Danish Institute for Applied Social Sciences Research, Copenhagen, Denmark
- Danish Cancer Society Research Centre, Copenhagen, Denmark
| | - Katja Grasic
- Centre for Health Economics, University of York, York, UK
| | | | - Mariama Touré
- Poverty, Health and Nutrition Division (PHND), International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | | |
Collapse
|
2
|
Waitzberg R, Gottlieb N, Quentin W, Busse R, Greenberg D. Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between Clinical and Economic Considerations? Int J Health Policy Manag 2022; 11:1823-1834. [PMID: 34634873 PMCID: PMC9808238 DOI: 10.34172/ijhpm.2021.87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 07/17/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Hospital professionals are "dual agents" who may face dilemmas between their commitment to patients' clinical needs and hospitals' financial sustainability. This study examines whether and how hospital professionals balance or reconcile clinical and economic considerations in their decision-making in two countries with activity-based payment systems. METHODS We conducted 46 semi-structured interviews with hospital managers, chief physicians and practicing physicians in five German and five Israeli hospitals in 2018/2019. We used thematic analysis to identify common topics and patterns of meaning. RESULTS Hospital professionals report many situations in which activity-based payment incentivizes proper treatment, and clinical and economic considerations are aligned. This is the case when efficiency can be improved, eg, by curbing unnecessary expenditures or specializing in certain procedures. When considerations are misaligned, hospital professionals have developed a range of strategies that may contribute to balancing competing considerations. These include 'reshaping management,' such as better planning of the entire course of treatment and improvement of the coding; and 'reframing decision-making,' which involves working with averages and developing tool-kits for decision-making. CONCLUSION Misalignment of economic and clinical considerations does not necessarily have negative implications, if professionals manage to balance and reconcile them. Context is important in determining if considerations can be reconciled or not. Reconciling strategies are fragile and can be easily disrupted depending on context. Creating tool-kits for better decision-making, planning the treatment course in advance, working with averages, and having interdisciplinary teams to think together about ways to improve efficiency can help mitigate dilemmas of hospital professionals.
Collapse
Affiliation(s)
- Ruth Waitzberg
- The Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute, Jerusalem, Israel
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Health Care Management, Faculty of Economics & Management, Technical University Berlin, Berlin, Germany
| | - Nora Gottlieb
- Department of Health Care Management, Faculty of Economics & Management, Technical University Berlin, Berlin, Germany
- Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Wilm Quentin
- Department of Health Care Management, Faculty of Economics & Management, Technical University Berlin, Berlin, Germany
- European Observatory on Health Systems and Policies, Brussels, Belgium
| | - Reinhard Busse
- Department of Health Care Management, Faculty of Economics & Management, Technical University Berlin, Berlin, Germany
- European Observatory on Health Systems and Policies, Brussels, Belgium
| | - Dan Greenberg
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| |
Collapse
|
3
|
Waitzberg R, Siegel M, Quentin W, Busse R, Greenberg D. It probably worked: a Bayesian approach to evaluating the introduction of activity-based hospital payment in Israel. Isr J Health Policy Res 2022; 11:8. [PMID: 35168669 PMCID: PMC8845384 DOI: 10.1186/s13584-022-00515-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 01/17/2022] [Indexed: 11/22/2022] Open
Abstract
Background In 2013–2014, Israel accelerated adoption of activity-based payments to hospitals. While the effects of such payments on patient length of stay (LoS) have been examined in several countries, there have been few analyses of incentive effects in the Israeli context of capped reimbursements and stretched resources. Methods We examined administrative data from the Israel Ministry of Health for 14 procedures from 2005 to 2016 in all not-for-profit hospitals (97% of the acute care beds). Survival analyses using a Weibull distribution allowed us to examine the non-negative and right-skewed data. We opted for a Bayesian approach to estimate relative change in LoS. Results LoS declined in 7 of 14 procedures analyzed, notably, in 6 out of 7 urological procedures. In these procedures, reduction in LoS ranged between 11% and 20%. The estimation results for the control variables are mixed and do not indicate a clear pattern of association with LoS. Conclusions The decrease in LoS freed resources to treat other patients, which may have resulted in reduced waiting times. It may have been more feasible to reduce LoS for urological procedures since these had relatively long LoS. Policymakers should pay attention to the effects of decreases in LoS on quality of care. Stretched hospital resources, capped reimbursements, retrospective subsidies and underpriced procedures may have limited hospitals' ability to reduce LoS for other procedures where no decrease occurred (e.g., general surgery). Supplementary Information The online version contains supplementary material available at 10.1186/s13584-022-00515-y.
Collapse
Affiliation(s)
- Ruth Waitzberg
- The Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute, Jerusalem, Israel. .,Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel. .,Department of Health Care Management, Faculty of Economics & Management, Technische Universität Berlin, Straße des 17. Juni 135, 10623, Berlin, Germany.
| | - Martin Siegel
- Department of Empirical Health Economics, Technische Universität Berlin, Straße des 17. Juni 135, 10623, Berlin, Germany
| | - Wilm Quentin
- Department of Health Care Management, Faculty of Economics & Management, Technische Universität Berlin, Straße des 17. Juni 135, 10623, Berlin, Germany.,European Observatory on Health Systems and Policies, Brussels, Belgium
| | - Reinhard Busse
- Department of Health Care Management, Faculty of Economics & Management, Technische Universität Berlin, Straße des 17. Juni 135, 10623, Berlin, Germany.,European Observatory on Health Systems and Policies, Brussels, Belgium
| | - Dan Greenberg
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| |
Collapse
|
4
|
Shiyovich A, Gilutz H, Arbelle JE, Greenberg D, Plakht Y. Temporal trends in healthcare resource utilization and costs following acute myocardial infarction. Isr J Health Policy Res 2020; 9:6. [PMID: 32051030 PMCID: PMC7017462 DOI: 10.1186/s13584-020-0364-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 01/29/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute myocardial infarction (AMI) is associated with greater utilization of healthcare resources and financial expenditure. OBJECTIVES To evaluate temporal trends in healthcare resource utilization and costs following AMI throughout 2003-2015. METHODS AMI patients who survived the first year following hospitalization in a tertiary medical center (Soroka University Medical Center) throughout 2002-2012 were included and followed until 2015. Length of the in-hospital stay (LOS), emergency department (ED), primary care, outpatient consulting clinic visits and other ambulatory services, and their costs, were evaluated and compared annually over time. RESULTS Overall 8047 patients qualified for the current study; mean age 65.0 (SD = 13.6) years, 30.3% women. During follow-up, LOS and the number of primary care visits has decreased significantly. However, ED and consultant visits as well as ambulatory-services utilization has increased. Total costs have decreased throughout this period. Multivariate analysis, adjusted for potential confounders, showed as significant trend of decrease in LOS and ambulatory-services utilization, yet an increase in ED visits with no change in total costs. CONCLUSIONS Despite a decline in utilization of most healthcare services throughout the investigated decade, healthcare expenditure has not changed. Further evaluation of the cost-effectiveness of long-term resource allocation following AMI is warranted. Nevertheless, we believe more intense ambulatory follow-up focusing on secondary prevention and early detection, as well as high-quality outpatient chest pain unit are warranted.
Collapse
Affiliation(s)
- Arthur Shiyovich
- Department of Cardiology, Beilinson Hospital, Rabin Medical Center, Rabin Medical Center, 39 Jabotinski Street, 49100, Petah Tikva, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Harel Gilutz
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Jonathan Eli Arbelle
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Maccabi Health Services, Southern Region, Beer-Sheva, Israel
| | - Dan Greenberg
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ygal Plakht
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Soroka University Medical Center, Beer-Sheva, Israel
| |
Collapse
|