The Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute, Jerusalem, Israel.
Department of Health Systems Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
Int J Health Policy Manag. 2021 Mar 15;10(5):244-254. doi: 10.34172/ijhpm.2020.51.
Since 2010, Israel has expanded the adoption of procedure-related group (PRG) based payments for hospitals. While there is a rich quantitative literature that assesses the effects of payment reforms on efficiency or quality of care, very few qualitative studies have focused on the impacts of diagnosis-related group (DRG)-like payments on hospitals from the perspective of hospital workers as change agents.
We used a qualitative, thematic analysis based on 33 semi-structured in-depth interviews with chief executive officers (CEOs), chief financial officers (CFOs), ward directors and physicians conducted in five public hospitals in Israel, sampled by maximum variation according to hospital characteristics.
Interviewees reported that the payment reform led to organizational changes such as increased transparency and enhanced supervision. Interviewees also reported several actions in response to the economic incentives of PRG-based payment. These included (1) shifting activities to afterhours and using operating rooms (ORs) more efficiently to enable increased surgical volumes; (2) reducing costs by shortening lengths of stay and increasing cost-consciousness in procurement; and (3) increasing revenues by improving coding and selecting procedures. Moderating factors reduced the effects of the reform. For example, organizational factors such as the public nature of hospitals or the (un)availability of healthcare resources did not always allow hospitals to increase the number of cases treated. Also, conflicting incentives such as multiple payment mechanisms or underpricing of procedures blurred the incentives of the reform. Finally, managers and physicians have many other considerations that outweigh the economic ones.
PRG payments affected the organizational dynamics of hospitals and changed decision-making about admission and treatment policies. However, such effects were moderated by many other factors that should be considered when shaping and analyzing hospital payment reforms.
自 2010 年以来，以色列已扩大采用与程序相关的分组（PRG）为医院支付费用。虽然有大量的定量文献评估了支付改革对效率或护理质量的影响，但很少有定性研究从医院工作人员作为变革推动者的角度关注类似于诊断相关分组（DRG）的支付对医院的影响。
我们使用了一种基于 33 名首席执行官（CEO）、首席财务官（CFO）、病房主任和医师的半结构化深入访谈的定性、主题分析，这些访谈是根据医院的最大变化特征在以色列的五家公立医院进行的。
受访者报告称，支付改革导致了组织变革，例如提高透明度和加强监督。受访者还报告了针对 PRG 为基础的支付的经济激励措施采取的几项行动。这些措施包括：（1）将活动转移到非工作时间，并更有效地利用手术室以增加手术量；（2）通过缩短住院时间和提高采购成本意识来降低成本；（3）通过改进编码和选择程序来增加收入。调节因素降低了改革的效果。例如，医院的公共性质或医疗资源的（无）可用性等组织因素并不总是允许医院增加治疗的病例数量。此外，多重支付机制或程序定价过低等冲突激励因素使改革的激励措施变得模糊。最后，管理人员和医生还有许多其他考虑因素，这些因素比经济因素更为重要。
PRG 支付影响了医院的组织动态，并改变了入院和治疗政策的决策。然而，许多其他因素对这些影响进行了调节，在制定和分析医院支付改革时应考虑这些因素。
