Are DRGs just? This is the primary question which this essay will answer. But there is a prior methodological question that also needs to be addressed: How do we go about rationally (non-arbitrarily) assessing whether DRGs are just or not? I would suggest that grand, ideal theories of justice (Rawls, Nozick) have only very limited utility for answering this question. What we really need is a theory of “interstitial justice,” that is, an approach to making justice judgments that is suitable (...) to assessing the social practices and institutions that comprise the interstices of our social life as opposed to its basic structure. Rawls's appeal to “our considered moral judgments” provides us with a useful starting point for this task, which we shall discuss in the first part of this essay. In the second part, we shall actually assess DRGs from the perspective of interstitial justice. What we shall show is that DRGs violate a large number of our considered judgments regarding a just approach to financing health care for the elderly in a cost-effective manner. This is true to such an extent that efforts to reform DRGs and make them fairer, such as the recent effort by Robert Veatch, should be abandoned. In the concluding section of the essay we discuss one especially pernicious feature of DRGs, namely, that they represent an invisible approach to rationing access to health care. In the minds of many this is one of the virtues of DRGs. That claim needs critical examination. (shrink)

Ostensibly, the DRG prospective payment system represents a modern effort to legislate an enforceable system of just prices. As a practical matter, however, justice is conflated with mere familiarity, and the real goal of DRGs has always been cost containment. Abstract and concrete discussions of the computation of DRG payment schedules illustrate their actual operation. Keywords: DRG, cost containment, just price, Medicare CiteULike Connotea Del.icio.us What's this?

DRGs may contain costs, but they threaten to restrict access to health care, to compromise its quality, and to impede the development of new medical technologies. Immediate corrections are necessary to ensure that hospitals continue to serve the poorest and sickest.

To allocate resources ethically under DRGs, we need an expanded medical ethics. Appealing to traditional patient-centred principles such as beneficence and autonomy will not be sufficient. We also need to take into account the social principles of full beneficence and justice. If marginal benefits must be eliminated, clinicians should not participate in deciding who should get less care but should remain committed to their patients' interests.

Commentary by Swami Tejomayananda. In this short and beautiful composition, Adi Sankara, the Master, has condensed the essence of Vedanta in just 31 verses, which are very useful to all serious seekers.

The goal of this article is to present the possibility of using Diagnosis- Related Groups (DRG) in the hospital management process and to analyse the need for business performance management on the part of hospital management staff. The following research methods were used: literature analysis, case studies, and poll analysis. It is not possible to increase the effectiveness of operation of healthcare entities without increasing the importance of IT systems and using DRG more effectively in the management process. Training users (...) in IT and the use of DRGs is important to achieving hospital effectiveness. The increased importance of analyses and planning in a hospital should be reflected in the organisational structure of service providers. Hospital controllers should have a similar role to those present in most companies in other industries. (shrink)

This series of articles by Charles Dougherty, Robert Berenson, and Kathleen Powderly and Elaine Smith, as well as “Cost Containment: Challenging Fidelity and Justice” by E. Haavi Morreim (Hastings Center Report, December 1988), result from a Hastings Center project, “Ethics and Prospective Payment Systems: DRGs.” The two-year project was jointly funded by The General Electric Foundation and the American Medical Association Education and Research Foundation.The project tried to gauge the systematic effects of the introduction of cost containment strategies, prospective payment (...) by Diagnostic Related Groups in particular, on the provision of health care and the ethical practice of medicine. Cost containment strategies, no matter how necessary in curbing spiraling medical costs, leave no sector or participants in the health care system untouched—hospitals and other health care institutions; doctors, nurses, social workers and other health care professionals; patients, their families, and the thirty-six to forty million medically indigent. The articles discuss the several and interrelated ethical issues raised by the DRG prospective payment system (Dougherty); its particular affect on the doctor-patient relationship and how it is transforming the ethical practice of medicine (Berenson and Morreim); and its specific impact on the professions and professional ethics of nursing and social work (Powderly and Smith). The overall message of the articles is that the health professions, their provision of care, and the ethics of their practices—as driven by economic considerations and realities—are in the midst of a more or less radical sea change. (shrink)

As they struggle to maintain high‐quality health care in the face of new economic limitations, physicians should not endanger their relationships with patients. But they should collectively revise the informal protocols that guide clinical decision making.

Die Einführung der kostenkalkulierten und landesweit einheitlich bepreisten DRGs hat die Möglichkeiten gewinnorientierter Krankenhausträger, ehemals kommunale, defizitäre Krankenhäuser in die Gewinnzone zu führen, erschwert. Diese reagieren darauf mit dem Einsatz bisher nicht gekannter Werkzeuge wie beispielsweise der Steuerung von Patientenströmen, Anreizsystemen, Gründung von Privatkliniken sowie erlösorientierten Therapien und Abrechnungen. Mittlerweile bedienen sich auch andere Trägergruppen dieser Instrumente, so dass sich die Frage stellt, ob angesichts der Wettbewerbssituation nicht gewinnorientierte Träger eines besonderen wirtschaftlichen Schutzes bedürfen, damit die bisher im Krankenhaus gültigen (...) ethischen Prinzipien auch weiterhin Anwendung finden können. (shrink)

Health Care Centres are institutions which, because of their specificity and character, are particularly exposed to various kinds of risk. One of the most important and most frequently used methods of risk management is the black spots method. The research material collected for the study comes from one of the hospitals in Wrocław. All hospital stays of the C22 (Face and Jaw Surgery Ward) and H05 (Injury and Orthopaedics Surgery Ward) settlement groups (DRG) were analysed - a total of 178 (...) hospitalisations. The black spots method was used in the study, which consisted of risk identification, the ordering of threats and proposals for remedial actions. Using the black spots method, it was possible to identify adverse events that occurred during the hospitalisation of patients with H05 and C22 DRGs in the Injury and Orthopaedics Surgery Ward and Facial and Jaw Surgery Ward. In both cases, the treatment costs for patients with complications were higher than for the stays without complications. (shrink)

Identification of the molecular mechanisms underlying axonal branching in vivo has begun in several neuronal systems, notably the projections formed by dorsal root ganglion (DRG) neurons or retinal ganglion cells (RGC). cGMP signalling is essential for sensory axon bifurcation at the spinal cord, whereas brain‐derived neurotrophic factor (BDNF) and ephrinA signalling establish position‐dependent branching of RGC axons. In the latter system, the degradation of specific signalling components, via the ubiquitin‐proteasome system, may provide an additional mechanism involved in axon branching of (...) RGC. The process of arborisation is essential for neurons to innervate multiple targets and to build topographic maps. The various forms of branching found in different types of neurons are regulated by distinct signalling pathways activated by multiple extracellular cues in addition to axonal guidance factors. These signalling cascades, together with transcriptional programs, most likely interact and trigger the polymerisation or depolymerisation of the actin and tubulin cytoskeleton to regulate branching. (shrink)

The federal government's introduction in 1983 of DRG‐based reimbursement for Medicare patients shook the entire health care industry into the vigorous and dramatic cost containment efforts which today are reshaping health care in America.

Seit der Einführung der G‑DRGs als Instrument zur Vergütung von Krankenhausleistungen steht das Gesundheitswesen als System unter Kritik. Denn die Ausrichtung der Krankenhäuser auf wirtschaftlichen Erfolg relativiert den Anspruch aller Bürgerinnen und Bürger auf gute medizinische Versorgung. Der Artikel geht der Frage nach, von welchem Akteur im System welche Aktivität erzwungen, erwartet, oder verlangt werden kann, dem entgegenzuwirken. Die genannten alltagsmoralischen Urteile werden unter Rückgriff auf Kants Moralphilosophie validiert und auf die wichtigsten Akteure angewandt. Ergebnis: Der Kern des Ökonomisierungs‑/Kommerzialisierungs-Problems besteht (...) in der Entwertung der Professionalität der patientennahen Berufe. Die Neujustierung des Systems kann vom Gesetzgeber nur dann verlangt werden, wenn die verfasste Ärzteschaft sich dazu bekennt, mit den ihr zu Gebote stehenden Mitteln gegen professionswidrige Handlungsanreize vorzugehen. (shrink)

This contribution deals with the issue of the professional autonomy ofthe medical doctor. Worldwide, the physician's autonomy is guaranteedand limited, first of all, by Codes of Medical Ethics. InItaly, the latest version of the national Code of MedicalEthics (Code 1998) was published in 1998 by the Federation ofprovincial Medical Associations (FnomCeO). The Code 1998acknowledges the physician's autonomy regarding the scheduling, thechoice and application of diagnostic and therapeutic means, within theprinciples of professional responsibility. This responsibility has tomake reference to the following (...) fundamental ethical principles:(1) the protection of human life; (2) the protection of thephysical and psychological health of the human being; (3) therelief from pain; (4) the respect for the freedom and the dignityof the human person, without discrimination; (5) an up-to-datescientific qualification (Art. 5). The authors underline that autonomyis an anthropological – and consequently ethical –characteristic of the human person. Different positions on autonomy inbioethics (individualistic, evolutionistic, utilitarian andpersonalistic models) are explained. The relation between theprofessional autonomy of the physician and the autonomy of the patientand of colleagues is discussed. In fact, the medical doctor isobliged: (1) to respect the fundamental rights of the person,first of all his/her life; (2) to ensure the continuity of thecare, even if he can only relieve the patient's suffering; (3) tomaintain, except under certain circumstances, professional secrecy andconfidentiality regarding patients and their medical records. Moreover,the physician cannot deny the patient correct and appropriateinformation. He/she should not perform any diagnostic or therapeuticactivity without the informed consent of the patient and the medicaldoctor must give up medical treatment in case of documented refusal ofthe individual. Furthermore, the medical doctor has the right to raiseconscientious objections if he/she is requested to perform medicalactions that are contrary to his/her conscience or medical opinion,unless this attitude would seriously and immediately harm the patient.Regarding the relationships with colleagues, the physician is obliged tosolidarity, mutual respect, and care of sick colleagues. Finally, theauthors discuss the Italian legislation affecting the physician'sprofessional autonomy: (1) the SSN health care Acts; (2) theso-called Charter for Public Health Care Services; (3) the Acts onprivacy; (4) Good Clinical Practice. (shrink)

Health information technology in hospitals can be approached as a tool to reduce health care costs and improve hospital efficiency and profitability, increase the quality of healthcare services, and make the transition to patient-centered healthcare. A hospital’s efficiency and profitability depends on linking IT with the knowledge and motivation of medical personnel. It is important to design and execute a knowledge management strategy as a part of the implementation of IT in hospital management. A Diagnosis-Related Groups system was introduced in (...) Poland in 2008 as a basis for settlements between hospitals and the National Health Fund. The importance and role of a DRG system in management of healthcare entities was emphasized based on a survey of medical professionals from two hospitals in the Lubelskie province. The goal of a survey is to assess the knowledge of medical professionals about the DRG system and how the medical personnel uses the DRG system in order to achieve the strategic goals of the organization. A newly developed survey was used to assess the medical personnel’s knowledge of DRG, using 12 closed and 5 open questions. The survey was conducted on 160 medical employees from two hospitals in the Lubelskie province. In conclusion, medical personnel’s DRG knowledge unambiguously contributes to reducing hospital costs and increasing profitability. The DRG related knowledge enables personnel to obtain value from data by applying DRG data-driven decisions. (shrink)

ZusammenfassungDie Einführung der kostenkalkulierten und landesweit einheitlich bepreisten DRGs hat die Möglichkeiten gewinnorientierter Krankenhausträger, ehemals kommunale, defizitäre Krankenhäuser in die Gewinnzone zu führen, erschwert. Diese reagieren darauf mit dem Einsatz bisher nicht gekannter Werkzeuge wie beispielsweise der Steuerung von Patientenströmen, Anreizsystemen, Gründung von Privatkliniken sowie erlösorientierten Therapien und Abrechnungen. Mittlerweile bedienen sich auch andere Trägergruppen dieser Instrumente, so dass sich die Frage stellt, ob angesichts der Wettbewerbssituation nicht gewinnorientierte Träger eines besonderen wirtschaftlichen Schutzes bedürfen, damit die bisher im Krankenhaus gültigen (...) ethischen Prinzipien auch weiterhin Anwendung finden können. (shrink)