Wolff-Menzler C, Große C
Psychiatrie und Psychotherapie, Universitätsmedizin Göttingen, Göttingen.
Professur für Finanzen und Controlling, Universität Göttingen, Göttingen.
Gesundheitswesen. 2015 May;77(5):e112-8. doi: 10.1055/s-0034-1374618. Epub 2014 Jun 17.
This paper surveys the effects of day-based lump-sum remuneration as defined by the PEPP system on the patients' length of stay and compares its incentives to the mechanisms of the German DRG system and the former remunera-tion system for stationary psychiatric and psychosomatic treatments.
The analysis identifies the economically optimal length of stay defined as the profit maximising duration of treatment by comparing marginal revenues and marginal costs. Since it is economically optimal to extend the treatment until the marginal costs exceed the marginal revenues, psychiatric and psychosomatic facilities are incentivised to minimise the time gap between average duration of treatment as expected duration of treatment and the economically optimal length of stay.
Compared to the German DRG system, which provides a strong incentive to reduce length of stay, the incentives set by the PEPP system imply either a reduction or an extension of treatment duration depending on the underlying cost function. If a degressive cost function is assumed, which is typical for treatments of psychiatric and psychosomatic illnesses, the economically optimal duration of treatment will be at the last upper boundary of the interval of the marginal revenue function in which the average marginal revenues exceed the average marginal costs. It is also feasible that it is economically optimal to treat the patient for as long as possible. The hospital is incentivised to extend or reduce the time of treatment to this point in time.
Psychiatric and psychosomatic hospitals are able to increase their profits by reducing or extending time of treatment. Therefore these facilities have to justify the extent of treatment to the health insurance companies. Since the incentives of the PEPP system and the DRG system diverge, the results of research on supply induced demand in the DRG system cannot be transferred to the discussion about the effects of the introduction of the PEPP system. As long as the average duration of treatment as expected duration of treatment deviates from the economically optimal length of stay, policy makers should consider the options of adaptations, i. e., increase of time intervals or calculating cost weights based on variable costs combined with separate remuneration of fixed costs. The TEPP system and PEPPplus are already being discussed as adaptions or additions.
本文考察了PEPP系统所定义的按日一次性支付薪酬对患者住院时间的影响，并将其激励机制与德国疾病诊断相关分组（DRG）系统以及之前针对住院精神科和身心疾病治疗的薪酬系统的机制进行比较。
该分析通过比较边际收益和边际成本，确定经济上最优的住院时间，即定义为使治疗利润最大化的持续时间。由于在经济上最优的做法是将治疗延长至边际成本超过边际收益，因此精神科和身心疾病治疗机构受到激励，要尽量缩小预期治疗持续时间即平均治疗持续时间与经济上最优住院时间之间的差距。
与强烈激励缩短住院时间的德国DRG系统相比，PEPP系统设定的激励措施意味着根据基础成本函数，治疗持续时间可能缩短或延长。如果假设成本函数递减，这在精神科和身心疾病治疗中很典型，那么经济上最优的治疗持续时间将处于边际收益函数区间的最后一个上限，在该区间内平均边际收益超过平均边际成本。也有可能在经济上最优的做法是尽可能长时间地治疗患者。医院受到激励将治疗时间延长或缩短至这一时间点。
精神科和身心疾病医院能够通过缩短或延长治疗时间来增加利润。因此，这些机构必须向健康保险公司说明治疗的程度。由于PEPP系统和DRG系统的激励措施不同，DRG系统中关于供给诱导需求的研究结果不能直接应用于关于引入PEPP系统效果的讨论。只要预期治疗持续时间即平均治疗持续时间偏离经济上最优的住院时间，政策制定者就应考虑调整方案，即增加时间间隔或根据可变成本计算成本权重并单独支付固定成本。目前正在讨论将TEPP系统和PEPPplus作为调整或补充措施。
