rMH 21, 2012, 13-15
From APDRG to SwissDRG: consequences for the Ente Ospedaliero Cantonale
The introduction, from January 1, 2012, of a unified national charging system (SwissDRG), presents new challenges to the Ente Ospedaliero Cantonale (EOC), a multi-site hospital with a total turnover of 550 Mil. CHF a year, 60% of which will fall under the new regulation. This article provides some insight into the DRG as a billing system for health services, singling out the relevant novelties introduced by the SwissDRG and by the new financing rules for hospitals, in order to identify possible negative repercussions on the quality of care and introduce the required correctives.
rMH 21, 2012, 16-20
DRG in the international context: which lessons for Switzerland?
The aim of the paper is threefold. In the first section, it describes the role of stewardship that governments are supposed to play in contemporary health systems and shows how the introduction of SwissDRG might improve two aspects of governance: performance measurement and holding to account. The second section explains the change of approach in hospital service reimbursement brought about by DRGs in comparison with the traditional per diem or fee-for-service payment. The features of the new reimbursement scheme appear in the terminology used in the international literature to qualify DRGs: “case payment”, “prospective payment”, “activity-based payment” and “pay-forperformance” are the terms used to describe its main properties. In the final section the paper highlights the hopes and fears related to the introduction of DRGs and discusses, on the basis of a recently performed review of the literature, which (positive or negative) effects have been systematically observed in countries adopting them. The conclusion argues that the final impact of DRGs is not deterministic but depends on many details related to contextual factors, to the efforts in quality monitoring and particularly to the wisdom in governing the implementation of the new system.
rMH 21, 2012, 21-26
The DRG from the standpoint of the medical profession
The introduction of DRGs is a catalyser, which can allow a rationalization of care processes in our hospitals. What would the introduction of DRGs entail for our health system? The question is pressing, although the implementation of the APDRGsystem and its diffusion in several cantons have already afforded a certain degree of practice on a similar system and have risen similar kinds of questions. How to recognize the possible negative effects of the change, in order to enforce the due counter-measures in time? It is necessary that the implementation of the change be accompanied by adequate surveys and by a long-term monitoring, in order to guarantee an effective health policy. The initiatives in this direction are numerous. Equally important is the consideration of analogous experiences: the comparison with the German experience can be most instructive, as the present paper argues.
rMH 21, 2012, 27-31
A multi-phased ethical challenge
The introduction of Diagnostic-Related Group payment in Swiss hospitals raises several kinds of ethical issues, which can easily be confused. This article briefly describes issues associated more generally with the payment of medicine, those which are more specifically associated with the introduction of the Swiss DRG system and its likely impact on clinical practices in Switzerland, and those which constitute general risks associated with institutional change and may be relevant here.
rMH 21, 2012, 65-73
The ancient roots of the neurosciences
The neurosciences are a new scientific domain which has developed in the last five decades, thanks to an effort to bring together different scientific and humanistic disciplines interested in the relation between mind and body. However, the theoretical debates around this subject date back to the origins of classical civilizations. The paper sketches a short history of the debates on the hierarchical structure of mental processes, suggesting the permanence in contemporary sciences of the platonic idea of a “tripartite soul”.
rMH 21, 2012, 74-83
A neurobiology of the soul
Knowledge of the brain allows understanding of some biological features of the mental processes underlying choices and decision making. According to a long tradition, choices and decisions, especially those involving a moral judgement, come from the “heart”, i.e. they emerge spontaneously and almost instinctively. Recent neuroscientific experiments have tried to test the possible natural roots of ethics: criticisms aside, a good deal of evidence supports a neuroanatomy of morals. Does the brain, then, contain the roots of valorial choices? Does the “heart”, i.e. emotions, guide us in interpersonal and social judgement? Information on the working of the brain, coming from outside, from science, and making new interpretations of human nature possible, make us aware of some of the natural roots of our reactions and tell us which, and how many, are the margins of our freedom. If this “external” gaze may lead us to hold as immutable what is “objectively” defined by the new technologies, it is important to always keep in mind that among the most salient features of the human brain are its plasticity (its capacity to modify structure and function in relation to experience) and its individual variability: a factor that stresses several degrees of freedom.
rMH 21, 2012, 84-89
A reflection on mistery, on the side of the shadows accompanying our paths, in order not to “die of too much light”. Without mysteries, the world would be poorer, and life more trivial. The mystery around humankind and its relation to the cosmos gives the very experience of life the flavour and colour of poetry, at times tragic, some other times happy. In a time when everything seems “scientifically” explainable (if not today, at least tomorrow), measurable, quantifiable, manipulable, under the rigid and totalitarian regime of calculating reason (which should have freed man from his illusions and enchantments) the shadows inhabiting both the world and ourselves do not look tamed at all. Darkness is never defeated, because it belongs to us, it is the sign of the secret “city” lying in our soul. The Medical Humanities are gaze, act and word capable of dialogue with mystery and its shadows, in order to narrate it as a noble part of the life- and illness-stories of every man, caregiver or patient. With mystery, which has nothing to do with the now-fashionable mysterism, goes a quest for another place, in which the deepest sense of our own existence lies.