Christian Ernst

Capped hospital budgets, risk-influencing activities and financial consequences

It has long been recognized in the health economics literature that increased financial incentives for better-informed health care providers may not only lead to desirable efficiency gains and cost savings. In addition, accounting-based cost containment instruments like capped budgets or prospective payment may induce physicians and hospitals to systematically avoid high-cost patients. Our paper uses an empirical approach backed by theoretical arguments to study a small German hospitals reactions to a major increase in financial incentives. We first describe essential features of the German hospital sector and developments that led to the introduction of capped budgets for hospital care in 1993. Next, incentives to treat high cost patients before and after the reform are analyzed in more detail. Using an anesthesia-related patient severity score (ASA score) as a proxy for financial patient risk, we empirically address the question how the distribution of ASA scores has changed over time at the hospital for the 1989-2002 period. Our analysis of detailed operating room data showed that the number of high risk patients (high ASA score) showed a systematic and significant decrease after the introduction of capped budgets. Using data from the new German DRG-reimbursement system, we also gain some preliminary evidence of the possible financial consequences of such practices.

Success of commonly used operating room management tools in reducing tardiness of first case of the day starts: evidence from German hospitals.

BACKGROUND: One of the declared objectives of surgical suite management in Germany is to increase operating room (OR) efficiency by reducing tardiness of first case of the day starts. We analyzed whether the introduction of OR management tools by German hospitals in response to increasing economic pressure was successful in achieving this objective. The OR management tools we considered were the appointment of an OR manager and the development and adoption of a surgical suite governance document (OR charter). We hypothesized that tardiness of first case starts was less in ORs that have adopted one or both of these tools. METHODS: Using representative 2005 survey data from 107 German anesthesiology departments, we used a Tobit model to estimate the effect of the introduction of an OR manager or OR charter on tardiness of first case starts, while controlling for hospital size and surgical suite complexity. RESULTS: Adoption reduced tardiness of first case starts by at least 7 minutes (mean reduction 15 minutes, 95% confidence interval (CI): 7–22 minutes, P < 0.001). CONCLUSION: Reductions in tardiness of first case starts figure prominently the objectives of surgical suite management in Germany. Our results suggest that the appointment of an OR manager or the adoption of an OR charter support this objective. For short-term decision making on the day of surgery, this reduction in tardiness may have economic implications, because it reduced overutilized OR time.

Cost Accounting Implications of Surgical Learning in the DRG Era - Data Evidence from a German Hospital

On January 1st 2004, Germany introduced a prospective payment system for the reimbursement of almost all inpatient hospital cases. The new system, which is based on Diagnosis Related Groups (DRGs), is now mandatory for all hospitals that treat patients insured under Germany’s statutory health insurance system (GKV). Although most German hospitals are currently exerting great efforts to calculate their individual DRG-costs, concerns have been raised whether such a system of administered fixed prices will be able to cope with medical innovation or quickly become obsolete. To gain insights into this question, an analysis of the dynamic properties of medical process innovations and their possible impact on the DRG system which is based on actual German data seems clearly merited. For two important medical innovations of the last two decades, a new method of knee replacement surgery and minimally invasive gall bladder removal (laparoscopic cholecystectomy), we empirically explore the question of whether the important cost driver “procedure time” displays a learning effect that accords with classical learning curve theory. Our principal results suggest that for these two high-cost, high-volume procedures, individual and organizational learning does indeed take place in the operating room. Based on these empirical results, we discuss our findings’ implications for hospital cost accounting in the era of DRGs.

Does Learning Matter for Knee Replacement Surgeries? Data Evidence from a German Hospital

In 2003, Germany will be the first country in the world to adopt a fully prospective payment system for the reimbursement of all inpatient hospital services. To face the increasing competition, hospitals can pursue either a specialization or a cost and quality leadership strategy. It stands to reason that organizational and individual learning will play an important role for both strategies. This paper raises the question, whether results from traditional learning curve theory can be applied to surgical procedures despite the latters heterogeneity. We develop a theoretical model of surgical learning and test it using detailed operating room data from the first 601 total knee replacement surgeries of a small German hospital between 1994–2000. Our results suggest that classical learning curve theory can indeed be applied to this high cost high volume procedure.

Agency-Theorie am Beispiel des LEN-Modells

In der folgenden Fallstudie werden einige wesentliche Erkenntnisse der okonomischen Agency-Theorie anhand des sogenannten LEN-Modells analysiert. Untersucht werden insbesondere die Beschaffung zusatzlicher Information vor dem Hintergrund des Controllability Principles sowie die Steuerung mehrerer Aktionen.

Abweichungsanalysen bei mehrstufigen Produktionsprozessen und deren Auswertung mit Hilfe des Modells von Bierman/Fouraker/Jaedicke

Diese Fallstudie befast sich zunachst mit Abweichungsanalysen bei mehrstufigen Produktionsprozessen gemas der Vorgehensweise nach Kloock/Dorner (1988). In einem zweiten Schritt werden Abweichungen einer Auswertung unterzogen. Hierzu wird insbesondere das Modell von Biermann/Fouraker/Jaedicke verwendet.

Die Kosten- und Leistungsrechnung als Entscheidungsrechnung

Die neu gegrundete Multi-Media OHG (M&M) montiert einen speziellen Typ von Power-PC. Samtliche Einzelteile werden fremd bezogen, und die M&M nimmt nur noch die Endmontage vor. Uber die Nachfrage der nachsten beiden Perioden herrscht jedoch Unsicherheit.

Koordination, Budgetierung und Anreize

Die Gartnerei FastGrow zuchtet Spezialgraser sowie Nadel- und Laubbaume, die beim Erreichen einer vorgegebenen Hohe verkauft werden. Aufgrund des unterschiedlich erforderlichen Know-hows ist das Unternehmen in drei Bereiche gegliedert.

Ausgewählte Aspekte des Zielkostenmanagements (Target Costing)

Die Fallstudie untersucht einige Aspekte des derzeit oft diskutierten Zielkostenmanagements. U. a. werden das Zielkostendiagramm, die Market into Company Methode und der Einfluss asymmetrischer Information zwischen Zentrale und Konstrukteuren analysiert.

Ausgewähltes Planungsproblem der Grenzplankostenrechnung

Die Fallstudie untersucht ein integriertes Planungsproblem, dessen Losung mit Hilfe von Instrumenten der GPKR abgeleitet werden kann.