David Scheller-Kreinsen

DRG-Based Hospital Payment Systems and Technological Innovation in 12 European Countries

OBJECTIVES To assess how diagnosis-related group-based (DRG-based) hospital payment systems in 12 European countries participating in the EuroDRG project pay and incorporate technological innovation. METHODS A standardized questionnaire was used to guide comprehensive DRG system descriptions. Researchers from each country reviewed relevant materials to complete the questionnaire and drafted standardized country reports. Two characteristics of DRG-based hospital payment systems were identified as particularly important: the existence of short-term payment instruments encouraging technological innovation in different countries, and the characteristics of long-term updating mechanisms that assure technological innovation is ultimately incorporated into DRG-based hospital payment systems. RESULTS Short-term payment instruments and long-term updating mechanisms differ greatly among the 12 European countries included in this study. Some countries operate generous short-term payment instruments that provide additional payments to hospitals for making use of technological innovation (e.g., France). Other countries update their DRG-based hospital payment systems very frequently and use more recent data for updates. CONCLUSIONS Generous short-term payment instruments to promote technological innovation should be applied carefully as they may imply rapidly increasing health-care expenditures. In general, they should be granted only if rigorous analyses have demonstrated their benefits. If the evidence remains uncertain, coverage with evidence development frameworks or frequent updates of the DRG-based hospital systems may provide policy alternatives. Once the data and evidence base is substantially improved, future research should empirically investigate how different policy arrangements affect the adoption and use of technological innovation and health-care expenditures.

Hospital payment based on diagnosis-related groups differs in Europe and holds lessons for the United States.

England, France, Germany, the Netherlands, and Sweden spend less as a share of gross domestic product on hospital care than the United States while delivering high-quality services. All five European countries have hospital payment systems based on diagnosis-related groups (DRGs) that classify patients of similar clinical characteristics and comparable costs. Inspired by Medicares inpatient prospective payment system, which originated the use of DRGs, European DRG systems have implemented different design options and are generally more detailed than Medicares system, to better distinguish among patients with less and more complex conditions. Incentives to treat more cases are often counterbalanced by volume ceilings in European DRG systems. European payments are usually broader in scope than those in the United States, including physician salaries and readmissions. These European systems, discussed in more detail in the article, suggest potential innovations for reforming DRG-based hospital payment in the United States.

Appendectomy and diagnosis-related groups (DRGs): patient classification and hospital reimbursement in 11 European countries

BackgroundAs part of the EuroDRG project, researchers from 11 countries (i.e., Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Sweden, and Spain) compared how their diagnosis-related groups (DRG) systems deal with appendectomy patients. The study aims to assist surgeons and national authorities to optimize their DRG systems.MethodsNational or regional databases were used to identify hospital cases with a diagnosis of appendicitis treated with a procedure of appendectomy. DRG classification algorithms and indicators of resource consumption were compared for those DRGs that together comprised at least 97% of cases. Six standardized case vignettes were defined, and quasi prices according to national DRG-based hospital payment systems were ascertained.ResultsEuropean DRG systems vary widely: they classify appendectomy patients according to different sets of variables (between two and six classification variables) into diverging numbers of DRGs (between two and 11 DRGs). The most complex DRG is valued 5.1 times more resource intensive than an index case in France but only 1.1 times more resource intensive than an index case in Finland. Comparisons of quasi prices for the case vignettes show that hypothetical payments for the most complex case vignette amount to only 1,005€ in Poland but to 12,304€ in France.ConclusionsLarge variations in the classification of appendectomy patients raise concerns whether all systems rely on the most appropriate classification variables. Surgeons and national DRG authorities should consider how other countries’ DRG systems classify appendectomy patients in order to optimize their DRG system and to ensure fair and appropriate reimbursement.

HOW WELL DO DIAGNOSIS‐RELATED GROUP SYSTEMS GROUP BREAST CANCER SURGERY PATIENTS?—EVIDENCE FROM 10 EUROPEAN COUNTRIES

We analysed patient-level data (n = 72,235) from 563 hospitals in 10 European countries to assess the ability of national diagnosis-related group (DRG) systems to account for patient-level variation in cost or lengths of stay of breast cancer surgery patients against a standard set of patient characteristics, treatment and quality variables. We find that European DRG systems use very different types of classification variables and numbers of DRGs (range: 3-7) to classify these patients. In 6 of 10 countries, the set of patient characteristics, treatment and quality variables, which we were able to define across countries, perform better than the set of national DRGs in accounting for patient-level variation in resource consumption. Moreover, there appear to be factors that are consistently significant determinants of cost/length of stay of breast cancer surgery cases but are not, or at least not fully, considered in European DRG systems. Our results therefore raise concerns as to whether all systems rely on the most appropriate classification variables. In several countries, policymakers should reevaluate the appropriateness of their DRG algorithm for breast cancer surgery and of specific DRG weights.

Patient-Level Hospital Costs and Length of Stay After Conventional Versus Minimally Invasive Total Hip Replacement: A Propensity-Matched Analysis

OBJECTIVES A current trend in total hip replacement (THR) is the use of minimally invasive surgery. Little is known, however, about the impact of minimally invasive THR on resource use and length of stay. This study analyzed the effect of minimally invasive surgery on hospital costs and length of stay in German hospitals compared with conventional treatment in THR. METHODS We used patient-level administrative hospital data from three German hospitals participating in the national cost data study. We conducted a propensity score matching to account for baseline differences between minimally invasively and conventionally treated patients. Subsequently, we estimated the treatment effect on costs and length of stay by conducting group comparisons, via paired t tests and Wilcoxon signed-rank tests, and regression analyses. RESULTS The three hospitals provided data from 2886 THR patients. The propensity score matching led to 812 matched pairs. Length of stay was significantly higher for conventionally treated patients (11.49 days vs. 10.90 days; P < 0.05), but total costs did not differ significantly (€6018 vs. €5986; P = 0.67). We found a difference in the allocation of costs, with significantly higher implant costs for minimally invasively treated patients (€1514 vs. €1375; P < 0.001) in contrast to significantly higher staff and overhead costs for conventionally treated patients. CONCLUSIONS Minimally invasive surgery was compared with conventional THR and was found to be associated with a reduced length of stay. Total hospital costs, however, did not differ between the two treatment groups, because of higher implant costs for minimally invasively treated patients.

DRG-Systeme in Europa

ZusammenfassungAufgrund ihrer Anreize und den damit potenziell einhergehenden Transparenz- und Effizienzgewinnen sind DRG-Systeme flächendeckend in Europa eingeführt worden. Bislang lagen jedoch keine Übersichtsarbeiten zu den unterschiedlichen europäischen DRG-Systemen mit ihren Stärken und Schwächen vor. Im Rahmen des EuroDRG-Projektes wurde diese Forschungslücke geschlossen. Dazu wurden europäische DRG-Systeme in zwölf Ländern mit unterschiedlichsten Gesundheitssystemen untersucht (Deutschland, England, Estland, Finnland, Frankreich, Niederlande, Irland, Österreich, Polen, Portugal, Schweden und Spanien). In der vorliegenden Arbeit werden die wesentlichen Ergebnisse dieser Analyse zusammengefasst. Es wird aufgezeigt, welche Unterschiede hinsichtlich der Politikziele, der Patientenklassifikation, der Datenerfassung, der Preissetzung und der Vergütung in den untersuchten DRG-Systemen bestehen und welche Herausforderungen sich daraus für ihre zukünftige Entwicklung ergeben. Dabei wird deutlich, dass die europäische DRG-Landschaft äußerst heterogen ist. Zwar ist der grundlegende DRG-Ansatz, das Gruppieren vergleichbarer Fälle, in allen Ländern ähnlich, aber im Design der wesentlichen Systembausteine gibt es teilweise große Unterschiede.AbstractDRG systems were introduced across Europe based on expected transparency and efficiency gains. However, European DRG systems have not been systematically analysed so far. As a consequence little is known about the relative strengths and weaknesses of different DRG systems. The EuroDRG project closed this research and knowledge gap by systematically analysing and comparing the DRG systems of 12 countries with different health systems (Austria, the UK, Estonia, Finland, France, Germany, Ireland, The Netherlands, Poland, Portugal, Spain and Sweden).This article summarizes the results of this analysis illustrating how DRG systems across Europe differ with regard to policy goals, patient classification, data collection, price setting and actual reimbursement. Moreover, it outlines which main challenges arise within and across the different types of DRG systems. The results show that the European DRG systems are very heterogeneous. Even if the basic DRG approach of grouping similar patients remains the same across countries, the design of the main building blocks differs to a great extent.DRG systems were introduced across Europe based on expected transparency and efficiency gains. However, European DRG systems have not been systematically analysed so far. As a consequence little is known about the relative strengths and weaknesses of different DRG systems. The EuroDRG project closed this research and knowledge gap by systematically analysing and comparing the DRG systems of 12 countries with different health systems (Austria, the UK, Estonia, Finland, France, Germany, Ireland, The Netherlands, Poland, Portugal, Spain and Sweden).This article summarizes the results of this analysis illustrating how DRG systems across Europe differ with regard to policy goals, patient classification, data collection, price setting and actual reimbursement. Moreover, it outlines which main challenges arise within and across the different types of DRG systems. The results show that the European DRG systems are very heterogeneous. Even if the basic DRG approach of grouping similar patients remains the same across countries, the design of the main building blocks differs to a great extent.

[DRG systems in Europe. Incentives, purposes and differences in 12 countries].

ZusammenfassungAufgrund ihrer Anreize und den damit potenziell einhergehenden Transparenz- und Effizienzgewinnen sind DRG-Systeme flächendeckend in Europa eingeführt worden. Bislang lagen jedoch keine Übersichtsarbeiten zu den unterschiedlichen europäischen DRG-Systemen mit ihren Stärken und Schwächen vor. Im Rahmen des EuroDRG-Projektes wurde diese Forschungslücke geschlossen. Dazu wurden europäische DRG-Systeme in zwölf Ländern mit unterschiedlichsten Gesundheitssystemen untersucht (Deutschland, England, Estland, Finnland, Frankreich, Niederlande, Irland, Österreich, Polen, Portugal, Schweden und Spanien). In der vorliegenden Arbeit werden die wesentlichen Ergebnisse dieser Analyse zusammengefasst. Es wird aufgezeigt, welche Unterschiede hinsichtlich der Politikziele, der Patientenklassifikation, der Datenerfassung, der Preissetzung und der Vergütung in den untersuchten DRG-Systemen bestehen und welche Herausforderungen sich daraus für ihre zukünftige Entwicklung ergeben. Dabei wird deutlich, dass die europäische DRG-Landschaft äußerst heterogen ist. Zwar ist der grundlegende DRG-Ansatz, das Gruppieren vergleichbarer Fälle, in allen Ländern ähnlich, aber im Design der wesentlichen Systembausteine gibt es teilweise große Unterschiede.AbstractDRG systems were introduced across Europe based on expected transparency and efficiency gains. However, European DRG systems have not been systematically analysed so far. As a consequence little is known about the relative strengths and weaknesses of different DRG systems. The EuroDRG project closed this research and knowledge gap by systematically analysing and comparing the DRG systems of 12 countries with different health systems (Austria, the UK, Estonia, Finland, France, Germany, Ireland, The Netherlands, Poland, Portugal, Spain and Sweden).This article summarizes the results of this analysis illustrating how DRG systems across Europe differ with regard to policy goals, patient classification, data collection, price setting and actual reimbursement. Moreover, it outlines which main challenges arise within and across the different types of DRG systems. The results show that the European DRG systems are very heterogeneous. Even if the basic DRG approach of grouping similar patients remains the same across countries, the design of the main building blocks differs to a great extent.DRG systems were introduced across Europe based on expected transparency and efficiency gains. However, European DRG systems have not been systematically analysed so far. As a consequence little is known about the relative strengths and weaknesses of different DRG systems. The EuroDRG project closed this research and knowledge gap by systematically analysing and comparing the DRG systems of 12 countries with different health systems (Austria, the UK, Estonia, Finland, France, Germany, Ireland, The Netherlands, Poland, Portugal, Spain and Sweden).This article summarizes the results of this analysis illustrating how DRG systems across Europe differ with regard to policy goals, patient classification, data collection, price setting and actual reimbursement. Moreover, it outlines which main challenges arise within and across the different types of DRG systems. The results show that the European DRG systems are very heterogeneous. Even if the basic DRG approach of grouping similar patients remains the same across countries, the design of the main building blocks differs to a great extent.

DRG-Systeme in Europa@@@DRG systems in Europe: Anreize, Ziele und Unterschiede in zwölf Ländern@@@Incentives, purposes and differences in 12 countries

ZusammenfassungAufgrund ihrer Anreize und den damit potenziell einhergehenden Transparenz- und Effizienzgewinnen sind DRG-Systeme flächendeckend in Europa eingeführt worden. Bislang lagen jedoch keine Übersichtsarbeiten zu den unterschiedlichen europäischen DRG-Systemen mit ihren Stärken und Schwächen vor. Im Rahmen des EuroDRG-Projektes wurde diese Forschungslücke geschlossen. Dazu wurden europäische DRG-Systeme in zwölf Ländern mit unterschiedlichsten Gesundheitssystemen untersucht (Deutschland, England, Estland, Finnland, Frankreich, Niederlande, Irland, Österreich, Polen, Portugal, Schweden und Spanien). In der vorliegenden Arbeit werden die wesentlichen Ergebnisse dieser Analyse zusammengefasst. Es wird aufgezeigt, welche Unterschiede hinsichtlich der Politikziele, der Patientenklassifikation, der Datenerfassung, der Preissetzung und der Vergütung in den untersuchten DRG-Systemen bestehen und welche Herausforderungen sich daraus für ihre zukünftige Entwicklung ergeben. Dabei wird deutlich, dass die europäische DRG-Landschaft äußerst heterogen ist. Zwar ist der grundlegende DRG-Ansatz, das Gruppieren vergleichbarer Fälle, in allen Ländern ähnlich, aber im Design der wesentlichen Systembausteine gibt es teilweise große Unterschiede.AbstractDRG systems were introduced across Europe based on expected transparency and efficiency gains. However, European DRG systems have not been systematically analysed so far. As a consequence little is known about the relative strengths and weaknesses of different DRG systems. The EuroDRG project closed this research and knowledge gap by systematically analysing and comparing the DRG systems of 12 countries with different health systems (Austria, the UK, Estonia, Finland, France, Germany, Ireland, The Netherlands, Poland, Portugal, Spain and Sweden).This article summarizes the results of this analysis illustrating how DRG systems across Europe differ with regard to policy goals, patient classification, data collection, price setting and actual reimbursement. Moreover, it outlines which main challenges arise within and across the different types of DRG systems. The results show that the European DRG systems are very heterogeneous. Even if the basic DRG approach of grouping similar patients remains the same across countries, the design of the main building blocks differs to a great extent.DRG systems were introduced across Europe based on expected transparency and efficiency gains. However, European DRG systems have not been systematically analysed so far. As a consequence little is known about the relative strengths and weaknesses of different DRG systems. The EuroDRG project closed this research and knowledge gap by systematically analysing and comparing the DRG systems of 12 countries with different health systems (Austria, the UK, Estonia, Finland, France, Germany, Ireland, The Netherlands, Poland, Portugal, Spain and Sweden).This article summarizes the results of this analysis illustrating how DRG systems across Europe differ with regard to policy goals, patient classification, data collection, price setting and actual reimbursement. Moreover, it outlines which main challenges arise within and across the different types of DRG systems. The results show that the European DRG systems are very heterogeneous. Even if the basic DRG approach of grouping similar patients remains the same across countries, the design of the main building blocks differs to a great extent.