2. Februar 2017 Krankenversicherung und Leistungsanbieter 1 Reinhard Busse, Prof. Dr. med. MPH FFPH FG Management im Gesundheitswesen, Technische Universität Berlin (WHO Collaborating Centre for Health Systems Research and Management) & European Observatory on Health Systems and Policies DRG Systeme in Europa Management im Gesundheitswesen Krankenversicherung und Leistungsanbieter
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2. Februar 2017 Krankenversicherung und Leistungsanbieter 1
Reinhard Busse, Prof. Dr. med. MPH FFPHFG Management im Gesundheitswesen, Technische Universität Berlin
(WHO Collaborating Centre for Health Systems Research and Management)&
European Observatory on Health Systems and Policies
DRG Systeme in Europa
Management im GesundheitswesenKrankenversicherung und Leistungsanbieter
Paymentmecha-
nism
Patient needs (risk
selection)
ActivityExpendi-
turecontrol
Technical efficiency
Trans-parency
QualityAdmini-strative
simplicityNumber of services/
case
Number of
cases
Fee-for-service + + + ― 0 0 0 ―
DRG based case payment
0 ― + 0 + + 0 ―
Global budget ― ― ― + 0 ― 0 +
Incentives ofdifferent forms of hospital payment
2Krankenversicherung und Leistungsanbieter2. Februar 2017
Paymentmecha-
nism
Patient needs (risk
selection)
ActivityExpendi-
turecontrol
Technical efficiency
Trans-parency
QualityAdmini-strative
simplicityNumber of services/
case
Number of
cases
Fee-for-service + + + ― 0 0 0 ―
DRG based case payment
0 ― + 0 + + 0 ―
Global budget ― ― ― + 0 ― 0 +
Incentives ofdifferent forms of hospital payment
European
countries 1990s/2000s
USA 1980s
“dumping” (avoidance), “creaming”
(selection) and “skimping” (undertreatment)
up/wrong-coding, gaming
3Krankenversicherung und Leistungsanbieter2. Februar 2017
Country Study Activity ALoS
US, 1983 US Congress - Office of
Technology Assessment, 1985
▼ ▼
Guterman et al., 1988 ▼ ▼
Davis and Rhodes, 1988 ▼ ▼
Kahn et al., 1990 ▼
Manton et al., 1993 ▼ ▼
Muller, 1993 ▼ ▼
Rosenberg and Browne, 2001 ▼ ▼
Empirical evidence (I): hospital activity and length-of-stay under DRGs
USA
1980s
4Krankenversicherung und Leistungsanbieter2. Februar 2017
Cf. Table 7.4 in Busse et al. 2011
European
countries
1990/ 2000s
Empirical evidence (II)
2. Februar 2017
Country Study Activity ALoS
Sweden,
early 1990s
Anell, 2005 ▲ ▼
Kastberg and Siverbo, 2007 ▲ ▼
Italy, 1995 Louis et al., 1999 ▼ ▼
Ettelt et al., 2006 ▲
Spain, 1996 Ellis/ Vidal-Fernández, 2007 ▲
Norway,
1997
Biørn et al., 2003 ▲
Kjerstad, 2003 ▲
Hagen et al., 2006 ▲
Magnussen et al., 2007 ▲
Austria, 1997 Theurl and Winner, 2007 ▼
Denmark, 2002 Street et al., 2007 ▲
Germany, 2003 Böcking et al., 2005 ▲ ▼
Schreyögg et al., 2005 ▼
Hensen et al., 2008 ▲ ▼
England,
2003/4
Farrar et al., 2007 ▲ ▼
Audit Commission, 2008 ▲ ▼
Farrar et al., 2009 ▲ ▼
France, 2004/5 Or, 2009 ▲ 5
Cf. Table 7.4
in Busse
et al. 2011
To get a common “currency” of hospital activity for
Prices for list B–DBCs in the Netherlandscan be negotiated Actual
reimbursement
• Volume limits
• Outliers
• High cost cases
• Quality
• Innovations
• Negotiations
2. Februar 2017 Krankenversicherung und Leistungsanbieter 34
Health care reform succeeded in lowering prices, but it did not curb volume growth
10
-0.54)
09
0.3
08
5.5
07
1.3
06
1.0
05
-0.9
04
0.1
03
2.1
02
7.4
01
11.0
00
5.3
99
5.6
Volume growth (%)
Generic
Inflation2)
10
4.0
09
6.4
08
5.4
07
4.3
06
3.2
05
4.6
04
6.4
03
4.1
02
5.4
01
2.8
00
0.1
99
0.2
• But since the health
care reform volume
growth accelerated
• Today’s challenge:
volume growth
reduction without the
waiting lists of the
1990s
• Health care reform
(competition) has
indeed led to lower
prices (driven by B-
segment)
The 2005-2006 Reform Paradigm• Volume growth is a fact of life: ageing,
innovation• More efficiency is needed to deal with
volume growth• Competition will lead to more efficiency
and lower prices
Strict
budgeting
Wait list
reduction
Health care reform:
competitions
09 10
3.5
6.8
08
10.9
04
6.5
03
6.2
02
12.9
07
5.6
06
4.1
05
3.7
01
13.8
00
5.4
99
5.8
Price increase (%)Total growth in hospital expenditures (%)1)
1) Hospital expenditure include day and/or night cost and include specialist health care (4) Estimate based on “Marktscan Medisch specialistische zorg2011”2) Consumer Price Index CBSSources: CBS Statline (Zorgrekeningen; expenditures at current and constant cost); RIVM Performance Of Dutch Health Care 2010; Stijging Zorgkostenontrafeld; VGE; Marktscan Medisch specialistische zorg 2011; BoStrategy& analysis
Actual reimbursement
• Volume limits
• Outliers
• High cost cases
• Quality
• Innovations
• Negotiations
2. Februar 2017 Krankenversicherung und Leistungsanbieter 35
Conclusions
• DRG-based hospital payment is the main method of provider payment in Europe, but systems vary across countries– Different patient classification systems
– DRG-based budget allocation vs. case-payment
– Regional/local adjustment of cost weights/conversion rates
• To address potential unintended consequences, countries– implemented DRG systems in a step-wise manner
– operate DRG-based payment together with other payment mechanisms
– refine patient classification systems continously (increase number of groups)
– place a comparatively high weight on procedures
– base payment rates on actual average (or best-practice) costs
– reimburse outliers and and high cost services separately
– update both patient classification and payment rates regularly
• If done right (which is complex), DRGs can contribute to increased transparency and efficiency – and possibly quality
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