Head-to-head comparison of fee-for-service and diagnosis related groups in two tertiary referral hospitals in Switzerland: an observational study
BACKGROUND: Reimbursement for inpatients in Switzerland differed among states until 2012. Some hospitals used diagnosis related groups (DRG) and others used fee-for-service (FFS). We compared length of hospital stay (LOS), patient satisfaction and quality of life between the two systems before a nation-wide implementation of DRG.
METHODS: In a prospective, two-centre observational cohort study, we identified all patients with a main diagnosis of either community-acquired pneumonia, exacerbation of chronic pulmonary obstructive disease, acute heart failure or hip fracture from January to June 2011 and performed a systematic questionnaire survey 2–4 months after hospital discharge.
RESULTS: Of 1,093 inpatients, 450 were included. Mean age was 71.1 (±SD 19.5) years (48% male). Patients in the FFS hospital were older (mean age 74.8 vs. 65.2 years; p <0.001) and suffered from more co-morbidities. Mean LOS was 9 days and shorter in the all-patient DRG (AP-DRG) hospital (unadjusted mean 8.2 vs. 9.5 days, p = 0.04). After multivariate adjustment, no significant difference in LOS was found (p = 0.24). More patients from the FFS hospital were re-hospitalised for any reason (35% vs. 17.5%; p = 0.01), re-admitted to acute-care institutions (11.7% vs. 5.2%; p = 0.014), not satisfied with the discharge process (15.3% vs. 9.7%; p = 0.02), showed problems with self-care (93.8% vs. 88%; p = 0.03) and usual activities (79.3% vs. 76%; p = 0.02).
DISCUSSION: This study suggested that the AP-DRG hospital showed higher patient satisfaction regarding discharge, lower re-hospitalisation rates and shorter LOS partly explained by a lower burden of co-morbidities and disease severity. This study needs validation in a larger cohort of patients and at multiple time points.
- Services CfMaM. National Health Expenditures 2010 Highlights. 2012.
- Office SFS. Health care costs and financing in 2010. 2012.
- Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: “She was probably able to ambulate, but I’m not sure”. JAMA. 2011;306(16):1782–93.
- Carratala J, Fernandez-Sabe N, Ortega L, Castellsague X, Roson B, Dorca J, et al. Outpatient care compared with hospitalization for community-acquired pneumonia: a randomized trial in low-risk patients. Ann Intern Med. 2005;142(3):165–72.
- Donaldson C, Magnussen J. DRGs: the road to hospital efficiency. Health Policy. 1992;21(1):47–64.
- Davis C, Rhodes DJ. The impact of DRGs on the cost and quality of health care in the United States. Health Policy. 1988;9(2):117–31.
- Rosenthal MB. Beyond pay for performance – emerging models of provider-payment reform. N Engl J Med. 2008;359(12):1197–200.
- Rosenthal MB. What works in market-oriented health policy? N Engl J Med. 2009;360(21):2157–60.
- Fischer, Wolfram. Die DRG Familie. 2008. Available at: http://www.fischer-zim.ch.
- Pretto M, Spirig R, Kaelin R, Muri-John V, Kressig RW, Suhm N. Outcomes of elderly hip fracture patients in the Swiss healthcare system: A survey prior to the implementation of DRGs and prior to the implementation ofa Geriatric Fracture Centre. Swiss Med Wkly. 2010;140:w13086.
- Schuetz P, Albrich WC, Suter I, Hug BL, Christ-Crain M, Holler T, et al. Quality of care delivered by fee-for-service and DRG hospitals in Switzerland in patients with community-acquired pneumonia. Swiss Med Wkly. 2011;141:w13228.
- Shaw JW, Johnson JA, Coons SJ. US valuation of the EQ-5D health states: development and testing of the D1 valuation model. Med Care. 2005;43(3):203–20.
- Schrag A, Selai C, Jahanshahi M, Quinn NP. The EQ-5D – a generic quality of life measure-is a useful instrument to measure quality of life in patients with Parkinson’s disease. J Neurol Neurosurg Psychiatry. 2000;69(1):67–73.
- Dodd S, Bassi A, Bodger K, Williamson P. A comparison of multivariable regression models to analyse cost data. J Eval Clin Pract. 2006;12(1):76–86.
- Grundlageninformationen zur Vergütung mit APDRG-Fallpauschalen. Available at: http://www.zmt.ch/stationaere_tarife/stationaere_tarife_apdrg/stationaere_tarife_apdrg_grundlageninformationen.htm.
- Busato A, von Below G. The implementation of DRG-based hospital reimbursement in Switzerland: A population-based perspective. Health Res Policy Syst. 2010;8:31.