Diagnosis-related group (DRG)-based case-mix funding system, a promising alternative for fee for service payment in China.

Fee for services (FFS) is the prevailing method of payment in most Chinese public hospitals. Under this retrospective payment system, medical care providers are paid based on medical services and tend to over-treat to maximize their income, thereby contributing to rising medical costs and uncontrollable health expenditures to a large extent. Payment reform needs to be promptly implemented to move to a prospective payment plan. The diagnosis-related group (DRG)-based case-mix payment system, with its superior efficiency and containment of costs, has garnered increased attention and it represents a promising alternative. This article briefly describes the DRG-based case-mix payment system, it comparatively analyzes differences between FFS and case-mix funding systems, and it describes the implementation of DRGs in China. China's social and economic conditions differ across regions, so establishment of a national payment standard will take time and involve difficulties. No single method of provider payment is perfect. Measures to monitor and minimize the negative ethical implications and unintended effects of a DRG-based case-mix payment system are essential to ensuring the lasting social benefits of payment reform in Chinese public hospitals.

Systematically evaluating the impact of diagnosis-related groups (DRGs) on health care delivery: a matrix of ethical implications.

Swiss hospitals were required to implement a prospective payment system for reimbursement using a diagnosis-related groups (DRGs) classification system by the beginning of 2012. Reforms to a health care system should be assessed for their impact, including their impact on ethically relevant factors. Over a number of years and in a number of countries, questions have been raised in the literature about the ethical implications of the implementation of DRGs. However, despite this, researchers have not attempted to identify the major ethical issues associated with DRGs systematically. To address this gap in the literature, we have developed a matrix for identifying the ethical implications of the implementation of DRGs. It was developed using a literature review, and empirical studies on DRGs, as well as a review and analysis of existing ethics frameworks. The matrix consists of the ethically relevant parameters of health care systems on which DRGs are likely to have an impact; the ethical values underlying these parameters; and examples of specific research questions associated with DRGs to illustrate how the matrix can be applied. While the matrix has been developed in light of the Swiss health care reform, it could be used as a basis for identifying the ethical implications of DRG-based systems worldwide and for highlighting the ethical implications of other kinds of provider payment systems (PPS).

[Ethical conflicts in pediatric surgery: high-performance medicine and the economical environment]. / Ethische Konflikte in der Kinderchirurgie : Hochleistungsmedizin und ökonomische Rahmenbedingungen.

BACKGROUND: Healthcare is increasingly influenced by economical constraints which can lead to ethical conflicts for surgeons. The aim of the study was to investigate the incidence of these conflicts and the coping strategies of surgeons. METHODS: A prospective, standardized staff survey in an academic pediatric surgical department was performed over a period of 4 weeks. The types of conflict and solution strategies were determined. The agreement with given statements was determined using a 5-point Likert scale. RESULTS: In 155 returned questionnaires 74 ethical conflicts were identified. Most conflicts concerned decisions relating to diagnosis-related groups (DRG) which were economically based. To resolve the ethical conflict surgeons decided to the detriment of patients in 73  % and to the economical benefit in 72 %. In 8  % a medical disadvantage for the patient was noted and in 62  % a disadvantage for patient comfort was seen. Surgeons were highly dissatisfied with the conflict solutions (2.3/5). CONCLUSIONS: Economical considerations cause ethical conflicts in the daily routine in pediatric surgery. Decisions are made to the benefit of the hospital and cause a decrease in patient comfort. Political solutions for this problem are required in the interest of all those involved.

Ethical research on the implementation of DRGs in Switzerland--a challenging project.

Diagnosis Related Groups (DRGs) are currently being introduced on a national scale as a prospective reimbursement scheme in Swiss in-patient hospital care, replacing any remaining retrospective day-rate arrangements. DRGs are expected to promote transparency and efficiency while helping to contain health care costs. The governmental decision to introduce DRGs has caused considerable controversy among different stakeholders, due to diverging appraisals of what will happen when DRGs are introduced as an economic management tool in Switzerland. The controversial discourse on DRGs is particularly interesting from an ethical point of view, since all arguments inevitably contain ethical considerations. In this paper we summarise the results of our exploratory ethical studies that have led to a larger research project funded by the Swiss National Science Foundation: "Impact of Diagnosis-Related Groups (DRGs) on patient care and professional practice" (IDoC). In section 1: 'Developing an understanding of the ethical issues at stake' we briefly explain how DRGs work, what the intended effects are, what the public is concerned about and what the scientific research tells us so far. In section 2: 'Developing an ethical framework for research on DRGs in Switzerland' we summarise the ethical issues and explain the ethical framework we will use in order to perform research on the complex issue of DRGs in Switzerland. Only once a profound understanding of the challenges exists can research on the ethical implications of DRGs be successful.

Grumblers in the time of Diagnosis-Related Groups: sand in the gear or lubricating oil?

OBJECTIVE: After the change from cost allowance to a German system of Diagnosis-Related Groups there has been much public discussion about how the new terms of employment within the health sector are increasingly in conflict with individuals'original motivations for their career choice. If such criticism remains unheard a further loss of employees might occur. METHODS: Two decades of professional experiences have been reviewed. The results were personally assessed and summarized in a field report. PARTICIPANTS: One senior physician, Department of Anesthesiology, University Hospital. RESULTS: In total, a deliberate contact approach by management to address employees' criticisms and grumbling about the terms of employment is essential for enterprise's success. CONCLUSIONS: While employees can introduce criticisms more constructively to contribute ideas that protect the enterprise'ssuccess, executives will have to position themselves in such a way as to be open to these perspectives. Constructive contact with "hospital troublemakers" should be implemented into the enterprise culture. Guidance is necessary to institute such changes.

[Precariousness, DRG's and health planning: pilot study at the Lariboisière hospital in Paris]. / Précarité, tarification à l'activité et planification sanitaire et sociale: étude pilote à l'hôpital Lariboisière de Paris.

OBJECTIVES: This paper considers the specific administrative procedures set up by managers of public healthcare establishments and those responsible for health and welfare policies to care for low-income pregnant women for whom 100% of the "price per act" (T2A) is refunded. What are the limitations and what improvements can be suggested? PATIENTS AND METHOD: The results are based on an analysis of data from semi-structured interviews, legislation and documents. RESULTS: The State, health insurance systems, public health establishments, local authorities, charities and outpatient services are involved in handling low-income parturients in different services and different establishments, both locally and regionally. A health and welfare policy comprising specific, coordinated actions and measures has been developed. The T2A "price per act" system may threaten its survival: the limited number of front-line facilities is often saturated and demand is increasing, treatment is often reduced to reactive management leading to unwanted readmissions, ethics are sometimes called into question and there is a risk of patient selection. DISCUSSION AND CONCLUSION: This pilot study provided some encouraging information but also indicated the limitations of the approach adopted. However, it was still of interest to see whether it was possible to use this approach, which did not require considerable resources, to reveal useful markers. This appeared to be the case. Regional Health Agencies (ARS) and local authorities could support the system. Additional funding is needed.

[Ethical insolvency?]. / Ethische Insolvenz?

The current DRG system has not only changed the economic structure of clinical medicine but also has profound effects on its original mission. In the present paper we discuss the fundamental limits of the DRG system and make a case for placing more emphasis on time and communication in health care.

[Ethics and diagnosis related groups]. / Ethik und Fallpauschalen. Welche Veränderungen in der Patientenversorgung sind zu erwarten?

At the turn of the year 2003/2004 a change took place in the in-patient sector of the German public health care system from the former daily-rate-based reimbursement of medical services to a reimbursement in accordance with diagnosis related groups (DRGs). At the same time, there are indications for a paradigm change in the allocation of medical services: away from the even provision of medical care across all country's municipalities towards a concentration in specialized medical centres - with uncertain ethical implications. On one hand, one hopes to cut costs in the in-patient area. On the other hand, it is questionable, whether cutting costs still allows an adequate treatment of multimorbid, chronically ill patients. The new system likely favours the active, autonomously deciding patient, who is capable of using additional information from the planned quality reports to obtain the best possible medical services. But the new system could create a disadvantage for the less informed patient groups, especially those who don't have easy access to such information. It is not our intention to idealise the German health care system before the invention of diagnosis related groups. Based on a survey of studies from the U.S., the article assesses consequences of such a system and relates them to ethical considerations.

[Guidelines and autonomy of physician decision. A critical survey under ethical aspects]. / Leitlinien und arztliche Entscheidungsspielräume--Eine kritische Bestandsaufnahme unter ethischem Aspekt.

The convergence of Diagnosis Related Groups (DRG) and Evidence-based Medicine (EbM) in the present German Health Care System Reform (GMG) leads, due to time constraints, to a misuse of EbM as cook-book medicine. The communication level of physicians has already shifted to abstract discussions of Randomized Controlled Trials (RCT) and guidelines, inducing per sea preference for pre-defined clinical decisions. The inconsistencies of evidence definitions, together with the overwhelming number of guidelines and providers thereof, burden medical reasoning with superfluous complexity, and contributing to the development of cook-book mentality. Without comprehensive trial registration of all RCTs before the start of a study, a publication bias will continue to exist. In the clinical practice, it is necessary to reduce the impact of study results and guidelines to a degree that remains compatible with patient interests and economy. In this field, prospective controlled outcome registries may provide a control for over- and faulty regulation. Clinical professionalism is characterized in parallel by a critical implementation of EbM and a necessary degree of independent reasoning.