Indførelsen af takststyring i det danske sygehusvæsen

Abstract

The subject of this thesis is the processes leading to the introduction of activity-based financing in the Danish hospital sector with special reference to the role of the concurrent development of a Danish DRG (Diagnosis-Related Groups) system. Using Actor-Network Theory (ANT) as an analytical framework relevant white papers from 1983-2003 as well as a few supplementary documents were studied, and nine interviews were performed of which five were classical semi-structured interviews. The main results were that the introduction of DRG for productivity measurements and benchmarking was recommended in white papers both in 1987 and 1994, but in 1987 nothing was done to follow up the recommendation, whereas in 1994-1996 a task group swiftly carried out a variety of productivity measurements using the American HCFA-8 classification and American cost weights. This lead to the publication of a national benchmark that was, however, heavily criticized by both the counties and the medical profession. Consequently, a number of physicians were enrolled in the task of developing a Danish DRG-system and Danish cost weights. The counties' objections were increasingly ignored and in 1997 a parliament majority voted for introducing DRG-based cross-county payment for non-specialised patients passing county borders. Since the Danish DRG-system was still in a process of development the parliament's decision and the developing DRG-system - in the language of ANT - co-opted each other and passed the point of no return. Shortly after this, the Liberals (Venstre) took an interest in DRG and activity-based financing and at some point actually considered the introduction of 100% activity-based financing of Danish hospitals. In the autumn of 1998, a parliament majority voted for the modest introduction of 10% activity-based financing, but even this was resisted by the counties and consequently never became effective. After the 2001 election, the political composition of the Danish parliament was dramatically altered resulting in a stable right-wing parliament majority, and the new Liberal-Conservative government could begin a stepwise introduction of activity-based financing as well as carrying out a structural reform that replaced the counties with five (weak) regions responsible for hospital management. It is concluded that the development of the Danish DRG system was probably postponed until the political 'climate' allowed parliament decisions that went against the counties' wishes, and that decisions concerning the DRG system and cross-county payment probably reinforced each other. However, there is no evidence that the development of the DRG system per se led to political decisions, since the system was far from developed when the first important decisions about cross-county payment and activity-based financing were made.