Abstract
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.
Highlights
Background “I basically live in an ethical dilemma all the time
I do not have a good way to deal [with this dilemma], because I am committed to my employer, to the organization where I work, but I am committed to patients” (Physician in orthopedic ward, Israel)
A clinically better treatment may be costeffective if it results in fewer complications and readmissions, and shortens average length of stays (ALoS): “All the beauty [in diagnosis-related groups (DRGs)-based payments] is that it is a tool to promote excellency: the better you are, the faster you can discharge the patient, the more money you make
Summary
Background “I basically live in an ethical dilemma all the time. And this ethical dilemma is very simple. Failure in one of them may threaten the survival of the organization.[2] The two objectives are often conflictive, but sometimes they can mutually reinforce each other.[3] Different units, professional groups and individuals prioritize different objectives in an organization.[4,5] For example, in healthcare organizations managerial staff may focus on economic goals whereas clinical staff may emphasize clinical safety This can create dilemmas for staff when deciding which objective should prevail. Sometimes efficiency can be improved, eg, by using cheaper, same quality, materials Another strategy is the planning of the treatment course in advance, including an organized pre-operative phase to avoid last-minute cancellations and start surgery on time. If these strategies are used beyond a certain limit, the balance between considerations is disturbed, potentially undermining quality of care and creating unnecessary expenditures
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