School of Law, Criminology and Government, Plymouth University, Plymouth, UK.
CERGAS Research Centre, SDA Bocconi Scuola di Direzione Aziendale, Milano, Lombardia, Italy.
J Health Organ Manag. 2020 Feb 8;34(3):295-311. doi: 10.1108/JHOM-10-2019-0295.
Attempts to transform health systems have in many countries involved starting to pay healthcare providers through a DRG system, but that has involved managerial workarounds. Managerial workarounds have seldom been analysed. This paper does so by extending and modifying existing knowledge of the causes and character of clinical and IT workarounds, to produce a conceptualisation of the managerial workaround. It further develops and revises this conceptualisation by comparing the practical management, at both provider and purchaser levels, of hospital DRG payment systems in England, Germany and Italy.
DESIGN/METHODOLOGY/APPROACH: We make a qualitative test of our initial assumptions about the antecedents, character and consequences of managerial workarounds by comparing them with a systematic comparison of case studies of the DRG hospital payment systems in England, Germany and Italy. The data collection through key informant interviews ( = 154), analysis of policy documents ( = 111) and an action learning set, began in 2010-12, with additional data collection from key informants and administrative documents continuing in 2018-19 to supplement and update our findings.
Managers in all three countries developed very similar workarounds to contain healthcare costs to payers. To weaken DRG incentives to increase hospital activity, managers agreed to lower DRG payments for episodes of care above an agreed case-load 'ceiling' and reduced payments by less than the full DRG amounts when activity fell below an agreed 'floor' volume.
RESEARCH LIMITATIONS/IMPLICATIONS: Empirically this study is limited to three OECD health systems, but since our findings come from both Bismarckian (social-insurance) and Beveridge (tax-financed) systems, they are likely to be more widely applicable. In many countries, DRGs coexist with non-DRG or pre-DRG systems, so these findings may also reflect a specific, perhaps transient, stage in DRG-system development. Probably there are also other kinds of managerial workaround, yet to be researched. Doing so would doubtlessly refine and nuance the conceptualisation of the 'managerial workaround' still further.
In the case of DRGs, the managerial workarounds were instances of 'constructive deviance' which enabled payers to reduce the adverse financial consequences, for them, arising from DRG incentives. The understanding of apparent failures or part-failures to transform a health system can be made more nuanced, balanced and diagnostic by using the concept of the 'managerial workaround'.
Managerial workarounds also appear outside the health sector, so the present analysis of managerial workarounds may also have application to understanding attempts to transform such sectors as education, social care and environmental protection.
ORIGINALITY/VALUE: So far as we are aware, no other study presents and tests the concept of a 'managerial workaround'. Pervasive, non-trivial managerial workarounds may be symptoms of mismatched policy objectives, or that existing health system structures cannot realise current policy objectives; but the workarounds themselves may also contain solutions to these problems.
许多国家在试图改革医疗体系时，都开始尝试通过按疾病诊断相关分组（DRG）系统向医疗服务提供者支付费用，但这涉及到管理上的权宜之计。管理上的权宜之计很少被分析。本文通过扩展和修改现有的关于临床和 IT 权宜之计的原因和特征的知识，对管理上的权宜之计进行了概念化。通过比较英国、德国和意大利在医院按 DRG 支付系统方面的提供者和购买者层面的实际管理，进一步发展和修改了这一概念化。
设计/方法/途径：我们通过比较英格兰、德国和意大利按 DRG 支付系统的案例研究的系统比较，对我们关于管理权宜之计的前提、特征和后果的初步假设进行了定性测试。通过关键信息员访谈（=154）、政策文件分析（=111）和一个行动学习小组进行数据收集，始于 2010-12 年，从 2018-19 年开始，通过关键信息员和行政文件的额外数据收集，补充和更新我们的发现。
所有三个国家的经理们都制定了非常相似的权宜之计来控制支付方的医疗成本。为了削弱 DRG 对增加医院活动的激励，管理人员同意降低高于商定病例量“上限”的护理病例的 DRG 支付，并在活动低于商定的“下限”量时减少低于全额 DRG 金额的支付。
研究局限性/影响：从经验上看，本研究仅限于三个经合组织的卫生系统，但由于我们的研究结果来自俾斯麦式（社会保险）和贝弗里奇式（税收资助）系统，因此它们可能更具广泛适用性。在许多国家，DRGs 与非 DRGs 或预 DRGs 系统并存，因此这些发现也可能反映了 DRG 系统发展的一个特定的、也许是暂时的阶段。可能还有其他类型的管理权宜之计，尚未研究。这样做无疑会进一步细化和细微调整“管理权宜之计”的概念化。
就 DRGs 而言，管理上的权宜之计是“建设性违规”的实例，使支付方能够减轻 DRG 激励措施给他们带来的不利财务后果。通过使用“管理权宜之计”的概念，可以更细致、更平衡和更具诊断性地理解卫生系统转型的明显失败或部分失败。
管理上的权宜之计也出现在卫生部门之外，因此，目前对管理上的权宜之计的分析也可能适用于理解教育、社会关怀和环境保护等部门的转型尝试。
创新性/价值：据我们所知，没有其他研究提出和测试“管理权宜之计”的概念。普遍存在的、非琐碎的管理权宜之计可能是政策目标不匹配的症状，或者是现有卫生系统结构无法实现当前政策目标的症状；但权宜之计本身也可能包含解决这些问题的办法。
