The Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute, Jerusalem, Israel.
Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
Int J Health Policy Manag. 2022 Sep 1;11(9):1823-1834. doi: 10.34172/ijhpm.2021.87. Epub 2021 Aug 15.
Hospital professionals are "dual agents" who may face dilemmas between their commitment to patients' clinical needs and hospitals' financial sustainability. This study examines whether and how hospital professionals balance or reconcile clinical and economic considerations in their decision-making in two countries with activity-based payment systems.
We conducted 46 semi-structured interviews with hospital managers, chief physicians and practicing physicians in five German and five Israeli hospitals in 2018/2019. We used thematic analysis to identify common topics and patterns of meaning.
Hospital professionals report many situations in which activity-based payment incentivizes proper treatment, and clinical and economic considerations are aligned. This is the case when efficiency can be improved, eg, by curbing unnecessary expenditures or specializing in certain procedures. When considerations are misaligned, hospital professionals have developed a range of strategies that may contribute to balancing competing considerations. These include 'reshaping management,' such as better planning of the entire course of treatment and improvement of the coding; and 'reframing decision-making,' which involves working with averages and developing tool-kits for decision-making.
Misalignment of economic and clinical considerations does not necessarily have negative implications, if professionals manage to balance and reconcile them. Context is important in determining if considerations can be reconciled or not. Reconciling strategies are fragile and can be easily disrupted depending on context. Creating tool-kits for better decision-making, planning the treatment course in advance, working with averages, and having interdisciplinary teams to think together about ways to improve efficiency can help mitigate dilemmas of hospital professionals.
医院专业人员是“双重代理人”，他们可能在患者的临床需求和医院的财务可持续性之间面临两难境地。本研究考察了在两个实行按活动计费支付系统的国家，医院专业人员在决策中是否以及如何平衡或协调临床和经济方面的考虑。
我们在 2018/2019 年对德国和以色列的五家医院的医院管理人员、首席医师和执业医师进行了 46 次半结构化访谈。我们使用主题分析来确定常见的主题和意义模式。
医院专业人员报告了许多情况下，按活动计费会激励适当的治疗，并且临床和经济方面的考虑是一致的。当效率可以提高时，例如通过遏制不必要的支出或专注于某些程序，情况就是如此。当考虑因素不一致时，医院专业人员已经制定了一系列策略，这些策略可能有助于平衡相互竞争的考虑因素。这些策略包括“重塑管理”，例如更好地规划整个治疗过程和改进编码；以及“重新构建决策”，这涉及使用平均值和开发决策工具包。
如果专业人员能够平衡和协调经济和临床方面的考虑因素，那么它们的不一致不一定会产生负面影响。背景对于确定考虑因素是否可以协调一致非常重要。协调策略是脆弱的，并且可能会根据上下文轻易受到干扰。创建更好决策的工具包、提前规划治疗过程、使用平均值以及建立跨学科团队共同思考提高效率的方法，可以帮助缓解医院专业人员的困境。
