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Effects of the DRG introduction: The economic logic becomes the measure of all things

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With the introduction of the diagnosis-related flat rate per case, the focus on economic goals continues to increase. This has a negative effect on patient care and on the daily work of doctors.

“When the patient comes in to the ward, I actually have to think about when will he go out again and how will he go out again. Practically on the first day I have to arrange everything so that it can continue to be supplied safely outside. "(Ward manager)

Since 2004, the hospitals no longer bill according to daily rates, but on the basis of diagnosis-related flat rates (DRG = Diagnosis Related Groups). Compared to the old system of daily rates, there are stronger incentives for economic behavior under DRG conditions: If the treatment of a patient is more complex than covered by the flat-rate remuneration, the hospital makes a loss. But if you succeed in working more economically than calculated when calculating the DRG flat rate, you can make a profit. With the introduction of the DRG, false incentives in the system were to be eliminated, the efficiency of the provision of services in the clinics increased and costs reduced. In order to evaluate the consequences of the introduction of the DRG in hospitals, the legislature has prescribed accompanying research (Section 17 b, Paragraph 8 of the Hospital Financing Act) - which has still not started three years after it was launched.
In the meantime, two independent research projects are investigating the effects of the changeover from daily rates to flat-rate flat rates for patients and employees in the clinics: a project at the University of Bayreuth and a joint study by researchers from the Science Center Berlin and the University of Bremen (see info box). The following remarks are based on the previous results of these projects, both of which are essentially based on detailed expert interviews with doctors, nurses, pastors and administrative staff.
On the quality of care
The introduction of the DRG system has direct and indirect effects on patient care. On the one hand, there are certain rules in the system that directly affect treatment, such as the lower and upper limit length of stay or incentives to fragment treatments. On the other hand, the introduction of DRG is increasing the pressure that has existed for years on hospitals to cut costs.


"We have to send patients home who are not yet 100 percent healthy - and that unfortunately increases the complication rate." (Assistant doctor)
According to the unanimous opinion of the study participants, the introduction of the DRG will help to further shorten hospital stays. As a result, however, the “bloody” layoffs feared beforehand are only sporadic. Most doctors and nurses state that discharge times are usually based on medical, not economic, criteria. It is criticized, however, that too many patients are discharged at a time when they are not yet healthy, are still in pain or have not yet fully regained their independence. As a result, the recovery process must partly take place outside the hospital. This is a burden, especially for the elderly.
The reduction in idle times goes hand in hand with a shift in services to the pre- and post-inpatient area. Part of the treatment chain is left to the general practitioners, which runs the risk of interrupting the continuity of treatment. In addition, the resident doctors are often not prepared for the additional patients because of the budget restrictions. Some clinicians complain that the treatment started in the hospital is sometimes not continued, expensive drugs are substituted or completely discontinued.


“If I operate on all three findings at once, then I can only get money for one. That can then lead to the fact that one says: 'I'll do the bile first, and in five weeks you will come back with the groin. Das The patient is the object with which profit is made. "(Senior doctor)
The trend towards treatment fragmentation has increased under DRG conditions. In order to be able to settle several cases, there is now a financial incentive to turn a longer stay into several short ones. It is less economical for a hospital to treat several illnesses of a patient during an inpatient stay. Because then only one main diagnosis can be billed at a time.
Due to the division into main and secondary diagnoses in the DRG system, there is also the risk that secondary diseases are taken less seriously or their treatment is shifted to other departments - a problem that is primarily addressed by the nursing staff. In some hospitals, secondary illnesses are at least still treated as a kind of "service".


“I recently talked to a nurse whose patient had died and who, after having been with him for a long time, was very confused and was actually unable to continue working at the moment. We talked for half an hour. And that stabilized the woman somewhat. And then she said: I have to work that into other patients again. "(Clinic chaplain)
The time for non-functional (interpersonal) communication is not provided under DRG conditions. Doctors and nurses report that they have less and less time to fully address the patient and his or her needs. The reasons given for this are the tight staffing levels, the burden of administrative activities, but also the shortening of idle times. The acceleration and consolidation of the work in the DRG system thus undermines human contacts - there is not enough time for care. Benevolence and attention are more and more lost in favor of maximizing revenue.
Although doctors and nurses repeatedly emphasize the importance of human contact, adequate communication and the establishment of trusting relationships, the interviews show that the DRG system undermines this claim. "Human contacts are clocked by economic logic," says Dr. theol. Arne Manzeschke, who heads the Bayreuth study. This means that detailed explanations to the patient and personal attention are neglected.


"I can see exactly which patients are now bringing little income here, but which require a relatively high amount of effort in inpatient diagnostics." (Senior physician)
There are different assessments of whether and how the introduction of the DRG will affect diagnostics. Some doctors do not (yet) see any influence of the DRG on diagnostics because they have always endeavored to carry out as little diagnostics as possible and to avoid expensive examinations as far as possible. Other doctors, however, do perceive changes. Since the idle times should be kept as short as possible and billing is no longer based on daily rates, a quick diagnosis is also sought.
If superfluous examinations have also taken place in the past, it is definitely in the interests of the patient to restrict diagnostic measures. “On the other hand, there is a risk that the necessary examinations will be omitted for economic reasons or that therapy decisions will not be secured,” fear Petra Buhr and Sebastian Klinke from the Berlin-Bremen project.
“But you can't let the number of diagnoses / cases on which we spend money increase indefinitely. That can only be a smaller part and has to be balanced with cases in which you make surpluses. And if that no longer works, then the hospital gets into trouble. And you have to recognize that as a doctor and then have to control it. "(Chief physician)
The new billing system tends to lead to patient selection. Manzeschke: "Lucrative patients are courted, less lucrative - not DRG-relevant‘ - passed on whenever possible. "Especially seriously injured and chronically ill patients are not adequately represented in the DRG system.
Treatment cases that do not pay off for the hospital must, according to the information, be limited to “justified exceptional cases” in order not to endanger the economic situation. As the economic pressure on hospitals increases towards the end of the convergence phase, Buhr and Klinke expect conflicts with the administration, for example over the admission of patients or the implementation of expensive treatments, to increase.
"Seen as a whole, the economically induced stress in the DRG system reduces the quality of medical services," concludes Manzeschke. "The consequences for the holistic treatment are most pronounced: on the one hand, the sick person with all their problems and needs is out of sight, on the other hand, the continuity of the treatment tends to be abolished and fragmentation is encouraged," say Buhr und Klinke.
For everyday work
The interviews show that the introduction of the new remuneration system has already had far-reaching consequences for the actions of the professions in the hospitals.


“Consciousness has changed. It is no longer so important how many beds you have, you just have to bring your case numbers. In the past, the bed was the status symbol. "(Chief Physician)
The DRG billing results in new orientation points with the number of cases. There are status changes and a restructuring of the hierarchy: The chief physicians lose power, in return the influence of the managers and economists increases. The medical staff sometimes seem unsettled in the face of these shifts in power. Unlike in other countries, however, the importance of nursing care in the course of the introduction of the DRG has tended to decrease in this country.


“The motivation has decreased significantly in recent years. Especially with those who have been working longer. Those who are new to the area do not know it any other way. Therein lies a certain chance, but otherwise the motivation has decreased significantly - up to fears, up to resignation, up to depression, up to occupational disability. "(Clinic chaplain)
The motivation of the nurses and doctors has mostly decreased. The reasons given are professional and social insecurities. Many employees feel overwhelmed, doctors in particular are frustrated and do not meet their own requirements. The doctors consistently emphasize that they would like to have more time for their patients, but in the DRG age they are obliged to document time-consuming documentation.


“It is no longer so lustful, that is, the fun is lost. If you look at people, you can see that the smile has disappeared. But if the smile disappears, then the patient notices it. And at that moment the patient is actually no longer the focus. "(Senior doctor)
In the DRG system, the pressure on the individual doctor increases to provide good and, as such, measurable services. Because the transparency is higher than in the old system. This increases the tension. But if the doctor loses his looseness and his enjoyment of the job, the patient feels this. As a result, the trust in the medical art of healing decreases. This in turn can have a negative effect on the success of the treatment.


“The commercialization of medicine turns many things in the doctor-patient relationship upside down. Because a complication is different than when I hand in a car and after a while the damage is not properly repaired. There are things that cannot be transferred from business to a doctor-patient relationship. "(Chief Physician)
The hospital is changing from a welfare institution to a service company that depends on customer loyalty and seeks to gain market competitiveness through specific unique selling points. The patient becomes a production factor that must be used as profitably as possible.
Many doctors are following this trend towards the economization of the health system with concern. Most of them endured the long working hours, poor pay and poor working conditions in the clinics for many years only because they drew strength and satisfaction from the doctor-patient relationship. A thank you, a smile or the certainty that a patient has found their way back to everyday life let some annoyance recede into the background. Are those times over?

“When I started 20 years ago, my approach was to say that I want to know as much as possible about the patients, and I want to have my anamnesis and diagnoses as precisely as possible and think about them as much as possible. Nowadays, when a patient comes, the first thing I really do is ask myself, when do I want to discharge him? I certainly still have a professional life of 20 years ahead of me. Will the DRG last that long? If I had to bet I would say no. I think I could still see bright minds explaining to us the advantages of the same-day care rate. "(Assistant doctor)
Jens Flintrop

literature
1. Buhr P, Klinke S: Qualitative consequences of the DRG introduction for working conditions and care in the hospital under conditions of continued budgeting, Vol. SP I 2006-311, WZB Discussion Paper. Berlin: Berlin Science Center for Social Research 2006.
2. Buhr P, Klinke S: Quality of care in the DRG era. First results of a qualitative study in four hospitals. ZeS working paper No. 6/2006. Bremen: Center for Social Policy 2006.
3. Manzeschke A: Global Health - Comments on economic ethics on the economization of the German health system. In: Yearbook for Science and Ethics, Volume 10, Berlin: De Gruyter 2005; 129-49.



The studies

Two projects are currently investigating the consequences of the introduction of the DRG for patients and employees:

Bremen / Berlin
The project “Change of Medicine and Care in the DRG System” (WAMP) (www.wamp-drg.de) is funded by the Hans-Böckler-Stiftung, Verdi, the GEK and the State Medical Association of Hesse and by the Berlin Science Center for Social Research and carried out by the Center for Social Policy at the University of Bremen. Petra Buhr and Sebastian Klinke have now presented the first results of the WAMP sub-study. 48 interviews were conducted in three municipal and one denominational hospital.

Bayreuth
“Diakonie and Economy. The effects of DRG and flat-rate medical and quality management on actions in hospitals. A sociological investigation and socio-ethical assessment ”(www.ethik.uni-bayreuth.de) is the name of the project at the Institute for Medical Management and Health Sciences at the University of Bayreuth. The Hans-Lilje-Foundation, Hanover, the Diakonische Dienst Hanover and the Andrea-von-Braun-Foundation support the study by Dr. theol. Arne Manzeschke and Thomas Pelz. 80 employees from seven hospitals (two municipal, four denominational and one private) were interviewed for the project.
Effects of the introduction of the DRG: The economic logic becomes the measure of all things

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