Project

Diagnosis Related Groups (DRGs); prospective payment system; conflicts of interest; indicators; hospital reimbursement; medical ethics; law; nursing science; health care services research; quality management; patient-centered care; professional practice; cost-containment in health care

Lead
Lay summary
Aims of the projectTo develop indicators and instruments that can help assess the impact of DRGs on patient care and professional practice. BackgroundDiagnosis Related Groups (DRGs) will be introduced in Swiss hospitals by 2012, based on a revision of the Swiss Health Insurance Law (KVG) in 2007. The new reimbursement system sets an incentive for health care professionals to concentrate on the main diagnosis of a patient and to discharge patients in an efficient manner. DRGs were developed in the USA in the 1960s and have subsequently been implemented in various countries. Several Swiss cantons have used DRGs for a number of years already.The implementation of cost-containment structures like DRGs has been controversial. A discussion on how to ethically allocate scarce health care resources has been ongoing for decades. There is an evolving consensus that resources are limited and their well-considered use is morally required. However, physicians or nurses working in structures that set incentives for cost-containment may perceive a conflict of interest: wanting to provide the best possible care to their patient on the one hand and wanting to be loyal to their institution and its economic viability on the other. Compromised quality of patient care, less equitable access to health care services, shifting delivery of health care to inadequately prepared institutions, and decreasing job satisfaction among health care workers are being projected if DRGs are being implemented.Despite its unquestioned importance, up to now no country has developed comprehensive evaluation and monitoring tools that address medically, ethically and legally relevant aspects. The project will take up this gap. The research group brings together expertise in the areas of medical ethics, law, nursing science, health services research and - through consulting experts - health economics, policy-making and management. MethodologyThe project focuses on three themes: 1) quality of health care, 2) access to health care and 3) job satisfaction of nurses and physicians (including perceived autonomy at work and compatibility of working conditions with health care worker's codes of ethics). The five subprojects (Medical Ethics, Law, Nursing Science, Health Services Research I and II) will use different methodological tools, such as qualitative interviews, quantitative surveys, analysis of health care monitoring instruments. The project will be coordinated by the Institute of Biomedical Ethics, University of Zurich. Regular meetings will be organized in order to achieve the best cooperation and synergies possible between the subgroups, external experts and stakeholders.

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Last update: 21.02.2013

Active participation

Self-organised

Active participation

Self-organised

Communication	Title	Media	Place	Year

Number	Title	Start	Funding scheme

As stipulated by the partial revision of the Federal Law on Health Insurance, Diagnosis Related Groups (DRGs) will be introduced as a prospective reimbursement system in Swiss in-patient hospital care by 2012, replacing the previous fee-for-service arrangements. This decision has caused considerable controversy among the different stakeholders, due to the diverging appraisals of what will happen when DRGs are introduced as economic management tools on a national scale. On the positive side, DRGs are expected to promote transparency and efficiency while helping to contain health care costs. On the negative side, compromised quality of patient care, less equitable access to health care services, shifting delivery of health care to inadequately prepared institutions such as nursing homes, and decreasing job satisfaction among nurses and physicians are being projected. Although the introduction of DRGs is supposed to be accompanied by an assessment of its economic effects and its consequences for health care quality, it is quite obvious that a narrow focus on cost efficiency and patient safety will not suffice to fully evaluate the concerns raised by the skeptical voices.To develop more comprehensive evaluation and monitoring tools that can address a spectrum of ethical and legal concerns about DRGs is a complex task that requires input from various disciplines. The research group assembled in the context of this proposal is uniquely positioned to carry out this task. It brings together expertise in the areas of medical ethics, law, nursing science, health services research and - through its network of consulting experts - health economics, policy-making and management. Ongoing pilot projects conducted by members of the group have already produced valuable insights and have identified relevant stakeholders (representing physicians, nurses, patients, hospital administrations, health insurers, the Swiss DRG cooperation, government officials and politicians). This will allow the project to proceed swiftly in the development of qualitative and quantitative tools as well as in the organization of workshops that will further methodological and normative discussions.The project will focus on three themes: 1) quality of health care (understood in a more comprehensive sense, including patient satisfaction), 2) access to health care and 3) job satisfaction of nurses and physicians (including parameters such as perceived autonomy at work and the compatibility of working conditions with health care worker’s individual or professional codes of ethics). It will provide empirical data on selected quality indicators as well as data on the perspectives of physicians, nurses and hospital administrators on the introduction of DRGs. These data will be compared to expectations raised in the literature and in expert and stakeholder interviews. The timing of the project (from fall 2010 through fall 2013) is ideal for this purpose, as it will allow baseline data to be gathered before the nationwide introduction of DRGs, while drawing on previous experiences with DRGs in Germany as well as in some Swiss cantons. It will also cover the early implementation phase of the DRG system, which can help identify potential causal factors triggering certain changes (e.g. shortened duration of hospital stays). Beyond the empirical data, the project will provide a critical analysis of the ethical and legal issues involved, and will provide a set of instruments, together with recommendations for future evaluation and monitoring. The methodological knowledge regarding the challenges and limits of assessing the impact of DRGs can also inform the assessment of other future health policy changes. Finally, the project expects to provide impulses for larger normative discussions on themes such as the tension between fair access to high quality health care, professional autonomy and cost-efficiency.