Paying hospital specialists: Experiences and lessons from eight high-income countries.

Payment systems for specialists in hospitals can have far reaching consequences for the efficiency and quality of care. This article presents a comparative analysis of payment systems for specialists in hospitals of eight high-income countries (Canada, England, France, Germany, Sweden, Switzerland, the Netherlands, and the USA/Medicare system). A theoretical framework highlighting the incentives of different payment systems is used to identify potentially interesting reform approaches. In five countries,most specialists work as employees - but in Canada, the Netherlands and the USA, a majority of specialists are self-employed. The main findings of our review include: (1) many countries are increasingly shifting towards blended payment systems; (2) bundled payments introduced in the Netherlands and Switzerland as well as systematic bonus schemes for salaried employees (most countries) contribute to broadening the scope of payment; (3) payment adequacy is being improved through regular revisions of fee levels on the basis of more objective data sources (e.g. in the USA) and through individual payment negotiations (e.g. in Sweden and the USA); and (4) specialist payment has so far been adjusted for quality of care only in hospital specific bonus programs. Policy-makers across countries struggle with similar challenges, when aiming to reform payment systems for specialists in hospitals. Examples from our reviewed countries may provide lessons and inspiration for the improvement of payment systems internationally.

Quality, cost, and their trade-off in treating AMI and stroke patients in European hospitals.

OBJECTIVES: This study compared the cost and in-hospital mortality of hospital care for two major diseases, acute myocardial infarction (AMI) and stroke, by pooling patient-level data from five European countries (Finland, France, Germany, Spain, and Sweden). We examined whether a cost-quality trade-off existed in these countries by comparing hospital-level costs and survival rates, and whether hospitals which performed well in terms of cost or quality in treating one patient group (AMI) performed well also in treating the other patient group (stroke). METHODS: A fixed-effect probit regression model for survival and the linear model for log costs were used to calculate indicators for hospital quality and cost, which were plotted against each other. FINDINGS: Both with AMI and stroke there were remarkable differences between hospitals and countries in (both crude and adjusted) rates of patients discharged alive. Swedish and French hospitals had lower mortality than hospitals in Germany, Finland and Spain in the care of AMI patients. However, a longer length of stay in Spanish and German hospitals may bias the results in the two countries. The Finnish hospitals seemed to have lower mortality than the other countries' hospitals in the care of stroke patients. There was no correlation at either the national or hospital level in the quality of treatment of these two diseases. We did not find a clear cost-quality trade-off. The only notable exception was Sweden, where the costs for AMI patients were higher in hospitals with the highest quality of care. CONCLUSIONS: Countries should identify the best performing hospitals both in terms of cost and quality in order to learn from hospitals that demonstrate better practice. It is equally important to better understand the reasons behind the observed differences between hospitals in costs and quality.

DRG systems in Europe: variations in cost accounting systems among 12 countries.

BACKGROUND: Diagnosis-related group (DRG)-based hospital payment systems have gradually become the principal means of reimbursing hospitals in many European countries. Owing to the absence or inaccuracy of costs related to DRGs, these countries have started to routinely collect cost accounting data. The aim of the present article was to compare the cost accounting systems of 12 European countries. METHODS: A standardized questionnaire was developed to guide comprehensive cost accounting system descriptions for each of the 12 participating countries. RESULTS: The cost accounting systems of European countries vary widely by the share of hospital costs reimbursed through DRG payment, the presence of mandatory cost accounting and/or costing guidelines, the share of cost collecting hospitals, costing methods and data checks on reported cost data. Each of these aspects entails a trade-off between accuracy of the cost data and feasibility constraints. CONCLUSION: Although a 'best' cost accounting system does not exist, our cross-country comparison gives insight into international differences and may help regulatory authorities and hospital managers to identify and improve areas of weakness in their cost accounting systems. Moreover, it may help health policymakers to underpin the development of a cost accounting system.

Performance of 10 European DRG systems in explaining variation in resource utilisation in inguinal hernia repair.

By classifying hospital output into groups of patients with similar clinical characteristics and resource requirements, diagnosis-related groups (DRGs) are designed to be highly correlated with resource utilisation. Using a two-stage approach to control for variation within and between hospitals, we examine the ability of the diverse DRG systems in 10 European countries to explain variability in resource utilisation (costs or length of stay, LoS) for hospital patients undergoing surgical repair of inguinal hernia. Our national regression results suggest that DRGs are statistically significant in explaining cost/LoS variation in the absence of any other regressors and generally remain so in most countries when patient-level characteristics are added to the model. However patient-level characteristics, including those used in DRG assignment, are usually also statistically significant. In nine countries, where the number of relevant DRGs ranges from two (Poland) to seven (France), the inclusion of patient-level characteristics substantially improves model goodness-of-fit compared with that attained with DRGs alone. Only in Sweden is the converse true. If our analysis raises some concerns over the adequacy of DRGs to explain cost/LoS variation in inguinal hernia repair in nine of the 10 European countries, further research is required to consider whether future enhancements may be necessary.

Have DRG-based prospective payment systems influenced the number of secondary diagnoses in health care administrative data?

Diagnosis-related groups (DRGs) are secondary patient classification systems based on primary classified medical data, in which single events of care are grouped into larger, economically and medically consistent groups. The main primary classified medical data are diagnoses and surgery codes. In Sweden, the number of secondary diagnoses per case increased during the 1990s. In the early 1990s some county councils introduced DRG systems. The present study investigated whether the introduction of such systems had influenced the number of secondary diagnoses. The nation-wide Hospital Discharge Register from 1988 to 2000 was used for the analyses. All regional hospitals were included, giving a database of 5,355,000 discharges. The hospitals were divided into those that had introduced prospective payment systems during the study period and those that had not. Among all regional hospitals, there was an increase in the number of coded secondary diagnoses, but also in the number of secondary diagnoses per case. Hospitals with prospective payment systems had a larger increase, starting after the system was introduced. Regional hospitals without prospect payment systems had a more constant increase, starting later and coinciding with the introduction of their DRG-based management systems. It is concluded that introduction of DRG-based systems, irrespective of use, focuses on recording diagnoses and therefore increases the number of diagnoses. Other reasons may also have contributed to the increase. It was found that the changes in the speciality mix, during the study period, have impact on the increase of secondary diagnoses.