Per case payment in Germany: all in a mess

Abstract

In 2000,the German government legislated a change to per case payment by DRG, and devolved the responsibility for design to an industry group of hospitals and insurance companies. In June 2002,the industry group formally announced that agreement could not be reached, and the Ministry of Health has consequently taken direct control. We argue that important decisions are consequently being made in haste (with significant risk of errors) and that sole-sourcing of some preparatory tasks (for reasons of time pressure) has disturbing aspects.We suggest three factors that might have contributed to this unfortunate state of affairs. First, Germany did not establish a largely independent research and development program of the style applied in Australia. Second, there was a failure to recognise at an early stage that the industry group was unlikely to reach the consensus required by its terms of reference, if only because of the significant competitive aspects of most elements of the design. Finally, too little was done to address the pervasive culture of mistrust between and among hospitals and insurers. We suggest that there needs to be talk about the process of talking if design work is to be more successful in future.