Systematically evaluating the impact of diagnosis-related groups (DRGs) on health care delivery: A matrix of ethical implications
Introduction
From the beginning of 2012, Swiss hospitals were required to implement a diagnosis-related groups (DRGs) based prospective reimbursement system for in-patient hospital care. Many hospitals had already been operating under a DRG system for several years, although this was the first time that a specific Swiss DRG system (developed from the German system)–‘SwissDRG’–was made obligatory for acute somatic care in most hospitals [1], [2]. Under the DRG-based system, hospitals are reimbursed a standard amount according to the number and type of cases they treat, rather than, for example, being reimbursed in the form of fee-for-service or per diem payment [1], [3], [4]. The Swiss system was implemented as part of a wider reform of hospital financing constituting a partial revision of the Federal Health Insurance Law (‘KVG’) [5].
After they were first introduced as a payment system for medicare in the US in 1983, a range of DRG-based systems have been implemented worldwide, including many European countries [6]. This kind of payment system is often implemented with the expectation that it will increase the transparency of hospital performance and resource consumption by standardizing reimbursement, and result in greater efficiency by encouraging appropriate care and discouraging unnecessary care [4], [7]. Indeed, in Switzerland a primary goal of the implementation of DRGs has been cited as an increase in efficiency and cost control by improving transparency and by increasing comparability between Swiss hospitals [1], [8].
Any health care reform can have a significant impact on health care delivery and, as such, needs to be assessed [9], [10]. Since their introduction, DRGs have generated research to determine their impact on, for example, cost and efficiency, the quality of health care, access to health care and the work satisfaction of health care practitioners [1], [3], [7], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25]. Despite the literature that DRGs have already generated, it is essential to understand precisely how DRGs work within the context of a particular country and its health care system. As part of a multidisciplinary group, we are conducting empirical and normative research in understanding the impact of DRGs in the Swiss context: the IDoC Project (Assessing the impact of DRGs on patient care and professional practice) [26]. There are also important gaps in the international literature that we aim to address. While concern has been raised about the impact of DRGs, for example, on ethically relevant factors such as the quality of health care and access to care, no systematic attempt has been made to identify the potential ethical implications of the implementation of DRG-based systems.
When we claim that something is ‘ethically relevant’ or has ‘ethical implications’ we mean that it is relevant to or has implications for significant social values, such as justice, for example. The problem with literature on DRGs and their ethical implications is that where DRGs and ethics are discussed at all, they are often discussed in relation to only one or two ethical values. What would be useful, particularly to policy-makers, would be to attempt to identify systematically which ethical values may be relevant to DRG-based systems overall.
With this in mind, we have developed the matrix presented in this paper. The matrix has helped us to group our research questions into categories according to the underlying ethical values, which enables us to understand the ethical implications of our research. However, it is not only intended as a means for our specific research. We have also explicitly developed this matrix for other researchers and policy-makers to help them to identify the ethical implications of DRG-based provider payment systems (PPS) and potentially other PPS, as well as to understand how their research or policies fit into a wider framework of ethics.
Section snippets
Material & methods
The research culminating in the matrix can be divided into three parts: (1) a literature review and empirical research on DRGs, (2) a review and analysis of ethical frameworks and (3) the analysis and systematization of steps 1 and 2.
Literature review and empirical research on DRGs
Our literature review and empirical research identified three major parameters of health care on which DRGs are most likely to impact: (1) the cost of health care and the efficiency with which it is provided, (2) the quality of care, and (3) equitable access to care. For example, DRGs are often expected to reduce patients’ average length of stay at hospitals (LOS) [18], [31], and subsequently, health care provisions might become more efficient. However, while some studies have indicated that
Systematizing the results
Systematizing the results from steps 1 to 2, led to the development of our matrix for identifying the ethical values associated with DRG-based PPS (see Table 1 below).
The matrix consists of 3 primary columns:
- (1)
The ethical values underlying the potential effects of the implementation of DRGs.
- (2)
The primary and secondary ethically relevant parameters of health care systems on which DRGs are likely to have an effect, as well as the processes of decision-making leading to the implementation of DRGs.
- (3)
Discussion
Developing a matrix for the ethical assessment of DRGs has several advantages. We believe that our framework can help researchers and policy-makers in health care to identify and address in a systematic manner the ethical implications of the implementation of DRGs. It can also be used to guide future research by indicating gaps in research on some of the ethical implications of DRGs. Additionally, this research and its classification according to the matrix can help to indicate areas of concern
Conclusion
Research on the ethical implications of DRGs tends to focus on isolated, ethically relevant parameters, for example, the focus is on how, if at all, a DRG-based PPS affects quality of care, and by implication, the ethical value underlying the quality of care. While this research is indeed very desirable, only having such research means that we lack scope—the focus on isolated ethically relevant issues does not indicate how research and policy questions on DRGs fit into a broader context of
Acknowledgement
The authors would like to thank Caroline Clarinval, Margrit Fässler and the other members of the IDoC research group for valuable comments. We thank Pingyue Jin for participating in several rounds of the development of the ethical matrix and for her feedback on the paper. We would also like to thank Daniel Strech and members of the Institute of Biomedical Ethics, Zurich, for their feedback. We are also grateful to an anonymous reviewer and the editors of Health Policy for providing feedback,
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