Performance Pay in Hospitals: An Experiment on Bonus–Malus Incentives

Recent policy reforms in Germany require the introduction of a performance pay component with bonus–malus incentives in the inpatient care sector. We conduct a controlled online experiment with real hospital physicians from public hospitals and medical students in Germany, in which we investigate the effects of introducing a performance pay component with bonus–malus incentives to a simplified version of the German Diagnosis Related Groups (DRG) system using a sequential design with stylized routine cases. In both parts, participants choose between the patient optimal and profit maximizing treatment option for the same eight stylized routine cases. We find that the introduction of bonus–malus incentives only statistically significantly increases hospital physicians’ proportion of patient optimal choices for cases with high monetary baseline DRG incentives to choose the profit maximizing option. Medical students behave qualitatively similar. However, they are statistically significantly less patient oriented than real hospital physicians, and statistically significantly increase their patient optimal decisions with the introduction of bonus–malus incentives in all stylized routine cases. Overall, our results indicate that whether the introduction of a performance pay component with bonus–malus incentives to the (German) DRG system has a positive effect on the quality of care or not particularly depends on the monetary incentives implemented in the DRG system as well as the type of participants and their initial level of patient orientation.

Incentives for Multimodal Treatment-first Step Towards Pay for Quality (P4Q) for Chronic Care: Health Services Research from Germany

Background: Pay for Quality (P4Q) is being discussed as an incentive to ensure high quality standards despite cost pressure in healthcare. However, P4Q can also have adverse effects, and the evidence for its effectiveness is limited, especially regarding chronic conditions and multimorbidity. For the treatment of the latter, specific evaluation criteria were defined. Whether these are feasible in the context of costs and remunerations is analyzed in this study using the German DRG system as an example. The aim is to show conditions under which P4Q can be effective. Methods and Results: Costs and remuneration for hospitals were compared for an exemplary geriatric indication, with and without complex treatment. Doing so, cost weights were shown to be more than triple for the latter. The results are applicable to health care systems with P4Q or similar approaches. Conclusion: Introducing complex treatments poses higher and costly demands regarding structure, processes, and interdisciplinary cooperation in organizations. Additional average costs can be calculated by comparison to regular treatment. Covering the extra costs creates the necessary conditions for P4Q and makes the implementation of complex treatments more likely. As high standards have to be guaranteed for complex treatments and patient satisfaction rises when these are introduced, quality improvements can be assumed. This study can inform Health policy (incentive models) medical societies, give impulses for quality management, and healthcare research (patient-oriented health, e.g. consumer-driven health care, shared decision-making). Future studies should report patient-related outcomes and investigate further diagnoses.

Trends and incidence of cartilage, ligament- and arthroscopic surgery: Analysis of German in-patient records 2005-2013

Aims and Objectives: Apart from some international cruciate ligament and arthroplasty register data, little epidemiological baseline facts are known about many joint surgical procedures. The German Federal Statistical Office collects the encoded population-based data of all medical in-patient procedures performed in Germany. The purpose of this study was to analyze these data to assess epidemiological trends and incidences in joint surgery. Materials and Methods: The comprehensive database of medical procedures of the German DRG system between 2005 and 2013, including 154 million anonymized in-patient records, were screened and analyzed for joint surgical procedures. Results: Trends of incidence rates of many joint surgical procedures have been detected. There was an increasing incidence of arthroscopic procedures in relation to the open procedures. Anterior cruciate ligament reconstruction or repair has a high incidence of 46 per 100,000 person-years, most popular grafts were hamstring tendon (90%) and patellar tendon (6.3%) autografts (2013). Conclusion: This is the first baseline epidemiological data out of 154 million in-patient records in Germany including joint and ligament surgical procedures with a focus on knee and shoulder surgery. The knowledge of the trends and incidences of these procedures help to validate and discuss the results of clinical studies and registers.

Economic Impact of Infected Total Knee Arthroplasty

Background.An enormous economic impact can be observed for infected total knee arthroplasties (TKA). The aim of the present study was to evaluate whether a cost covering treatment of infected TKA is feasible in the German DRG System.Patients and Methods.Average total treatment costs were evaluated for infected TKA and compared with a matched pair of primary TKA. Data was generated using the health record and the hospitals’ health information system. Results were evaluated and compared regarding the total personnel and material costs with respect to the financial receipts.Results.A total of 28 patients diagnosed with an infected TKA were included. A significant increase in the average length of stay, use of medical supplies and third party medical examinations were found for the infected TKA. An average deficiency of 6,356€ per patient was observed for the infected TKA. An average profit of 927€ per patient was made performing primary TKA.Conclusions.A cost-effective treatment of infected TKA was not feasible with the receipts from the German DRG System. An adaption of the receipts has to be evaluated. Moreover, other measures have to be considered in order to achieve a comprehensive medical yet financial reasonable standard in the treatment of infected TKA and THA.