Secondary care: hospital financing

This chapter discusses the three most widely used payment systems for hospitals. While concepts differ, payment models in secondary care have parallels to those used in primary care. In retrospective systems, providers’ costs are fully reimbursed after they have incurred which leads to cost escalations and inefficiencies. In prospective systems, payments are determined ex ante without any link to the real costs incurred by the provider. Prospective payment systems are of two kinds: variable or fixed. The former are often referred to as activity-based financing, while fixed payments refer to block grants or global budgets. The three models are compared emphasizing their pros and cons. In practical policy, prospective activity-based funding has increased in popularity, but many countries opt for a blended model involving a fixed budget together with activity-based incentives. The chapter ends with a brief discussion of various pay-for-performance schemes.

Impact of new health care policies on the quality of acute myocardial infarction treatment in Swiss hospitals: A before and after observational study

Objective: Following a revision of the Swiss Federal Health Insurance Act, the regional hospital planning structure was modified and the hospital financing organized at a national level with the use of diagnosis related groups (SwissDRGs). The aim of this observational study was to determine in an independent way the initial impact of these changes on the quality of hospital treatment, with patients hospitalized for Acute Myocardial Infarction (AMI) being the chosen study group.Methods: We used prospective data from a Swiss clinical registry for AMI. The quality was measured based on the adherence to 10 evidence-based performance indicators for AMI treatment, and on the evaluation of in-hospital outcomes (mortality, complications, length of hospital stay [LOS]) globally and for seven pre-defined vulnerable subgroups. The study compared patient-based data before (2011) and after (2012) the implementation of the reform.Results: The study included 33 matched hospitals, and compared the AMI treatment of 2,491 patients in 2011 (before) and 2,544 in 2012 (after the hospital reform). No significant changes in the evidence-based performance indicators were observed, but an on average one day reduction in the LOS and worse outcomes in one of the pre-defined group of patients were found. The issue of how the clinical team achieved these results was not directly explored due to the underlying registry’s unalterable structure.Conclusions: One year after the implementation of a new hospital financing system in Switzerland, the quality of treatment delivered to patients hospitalized for AMI was maintained overall. The worse in-hospital mortality in one pre-defined vulnerable subgroup could reflect the emergence of difficulties for clinical teams to cope with patients demanding extra care and time. Further investigation is warranted.