1. SUMMARY
I. BACKGROUND: Cost containment is a major concern for contemporary health care systems that aim to sustain afford-able health care of good quality. Switzerland has followed other countries: since 2012 Swiss acute-care hospitals have been required to use Diagnosis-Related Groups (SwissDRG) as reimbursement system for inpatient care, implemented as part of a wider health care reform. In our previous study we analysed the legal framework governing SwissDRG and interviewed hospital managers to explore how hospitals react to the DRG-based reimbursement system. We found that the changing economic incentives in inpatient care induce a shift in the service supply of hospitals. Especially services with a high proportion of nursing care (“Pflege”) are less attractive for hospitals. Our research has also clearly shown that important gaps persist concerning the evaluation of changes triggered by the introduction of DRGs in Switzerland.
First, data is lacking about inpatient-outpatient transitions. It is of crucial importance to determine what the conse-quences are if inpatient care is now often terminated earlier than in the past or shifted outside hospitals. The interviewed experts perceive unambiguously the transition from acute care to transitional and Spitex care as dysfunctional. Existing problems aggravated by the reported cost shift towards the outpatient sector are not solved.
Second, in previous research patient trajectories have not been the focus. This means that we don’t know enough about patients’ long term, sequential courses and histories that are better able to shed light on the transitions between different care types. We also don’t know enough about the factors that influence these transitions. Our working hypothesis would be that health care providers such as hospitals and institutional physicians, treating physicians and patients have distinct possibilities and incentives to influence these transitions. It is also evident that the legal and wider regulatory frame-work and the different financing systems are factors that influence the transitions.
Third, past research on the new hospital funding and the introduction of SwissDRG has focused above all on the chang-es in the legal basis for hospital funding and its impact. A comprehensive and patient oriented view must also take into account another important change of the Swiss social security law: since 1.1.11, the amendments on the reorganisation of the financing of care from the Federal Law of 13.6.08 apply. This interplay between the new hospital financing and financing of inpatient and outpatient care provided by nursing homes and home care organisations needs to be studied in detail. There is a lack of studies examining to what extent these two reformed financing systems interfere with the decisions of providers and insured persons. Existing self-reported data indicate that “acute and transitional care measures” (ATC) have so far either not or only partially been implemented and, if implemented, significant cantonal variations exist as to the self-participation of the insured patients and detailed financing schemes. Given the rapidly rising costs in the financing of care, it seems urgent to analyse this relationship on the one hand legally, but on the other hand also empirically. In particular, it must be born in mind that the system of supplementary benefits to the old age and survivors insurance scheme and the disabilities insurance scheme (Ergänzungsleistungen AHV/IV) has been upgraded to a proper tax-funded nursing care in the context of the new system of care financing. Many factors that influence decisions of patients and care providers have changed in this context, which has not been investigated by legal science or medico-social studies.
The present study uses an interdisciplinary approach which is necessary to address the existing knowledge gap concern-ing inpatient-outpatient transitions.