Skip to main content
Log in

Cost Accounting Implications of Surgical Learning in the DRG Era — Data Evidence from a German Hospital

  • Published:
Schmalenbach Business Review Aims and scope

Abstract

On January 1st 2004, Germany introduced a prospective payment system for the reimbursement of almost all inpatient hospital cases. The new system, which is based on Diagnosis Related Groups (DRGs), is now mandatory for all hospitals that treat patients insured under Germany’s statutory health insurance system (GKV). Although most German hospitals are currently exerting great efforts to calculate their individual DRG-costs, concerns have been raised whether such a system of administered fixed prices will be able to cope with medical innovation or quickly become obsolete. To gain insights into this question, an analysis of the dynamic properties of medical process innovations and their possible impact on the DRG system which is based on actual German data seems clearly merited. For two important medical innovations of the last two decades, a new method of knee replacement surgery and minimally invasive gall bladder removal (laparoscopic cholecystectomy), we empirically explore the question of whether the important cost driver “procedure time” displays a learning effect that accords with classical learning curve theory. Our principal results suggest that for these two high-cost, high-volume procedures, individual and organizational learning does indeed take place in the operating room. Based on these empirical results, we discuss our findings’ implications for hospital cost accounting in the era of DRGs.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  • 3M Media (2002), Health Information Services Institute, Neuss. Kalkulation der ersten deutschen Bewertungsrelationen für das G-DRG System, Band 1: Projektbericht, Band 2: G-DRG Tabellen.

  • Amtliche Begründung zum Gesetz zur Einführung des diagnose-orientierten Fallpauschalensystems für Krankenhäuser (Fallpauschalen-Gesetz FPG), BMG 216 v. 20.08.2001.

  • Arnold, Michael and Rüdiger Strehl (2001), Wie kommen Innovationen ins DRG-System? (Die Steuerungsfunktion der Bundesausschüsse), in Arnold, Michael, Martin Litsch, and Henner Schellschmidt (eds.), Krankenhaus-Report 2000 — Schwerpunkt: Vergütungsreform mit DRGs, 159–171.

  • Arrow, Kenneth J. (1963), Uncertainty and the Welfare Economics of Medical Care, American Economic Review 53, 941–973.

    Google Scholar 

  • Arvidsson, S., J. Ouchterlony, L. Sjostedt, and K. Svardsudd (1996), Predicting postoperative adverse events. Clinical efficiency of four general classification systems. The project perioperative risk, Acta Anaesthesiologica Scandinavica 40, 783–791.

    Article  Google Scholar 

  • Bähr, K. and K. Ellinger (2001), Ablaufoptimierung im OP-Bereich durch Implementierung eines Qualitätszirkels, Anästhesiologie & Intensivmedizin 42, 76–87.

    Google Scholar 

  • Baloff, Neal (1966), The Learning Curve: Some controversial issues, Journal of Industrial Economics 14, 275–282.

    Article  Google Scholar 

  • Baldwin, Duane, Jennifer Dunbar, Dipen J. Perekh, Nancy Wells, Matthew D. Shuford, Michael S. Cookson, Joseph A. Smith Jr., S. Duke Herrell, Sam S. Chang, and Elspeth M. McDougall (2003), Single-center comparison of purely laparoscopic, hand assisted laparoscopic, and open radical nehprectomy in patients at high anesthetic risk, Journal of Endourology 17, 161–167.

    Article  Google Scholar 

  • Billing, Arend, Monika Thalhammer, and Michael Pflaum (2003), Hauseigene Kalkulation der DRG-Kosten als Hilfe für die Zukunftsplanung, führen und wirtschaften im Krankenhaus 20, 450–452.

    Google Scholar 

  • Boston Consulting Group (1970), Perspectives on experience, Second Edition, Boston: Mass.

    Google Scholar 

  • Braun, Guenther (1997), Unternehmensberatungen bieten unterschiedliche Leistungen — Studie ermöglicht Krankenhäusern Vergleich, führen und wirtschaften im Krankenhaus 14, 41–43.

    Google Scholar 

  • Breßlein, Susanne (2000), AR-DRG, Australian Refined Diagnosis Related Groups, führen und wirtschaften im Krankenhaus 17, 590–592.

    Google Scholar 

  • Breßlein, Susanne (2003), Erste Erfahrungen eines Frühumsteigerkrankenhauses, führen und wirtschaften im Krankenhaus 20, 212–214.

    Google Scholar 

  • Breyer, Friedrich, Peter Zweifel, and Mathias Kifmann (2003), Gesundheitsökonomie, Fourth Edition, Berlin et al.: Springer Verlag.

    Book  Google Scholar 

  • Buxton, Martin (1987), Problems in the economic appraisal of new health technology: The evaluation of heart transplants in the UK, in Drummond, Martin (ed.), Economic appraisal of health technology in the European Community, Oxford: Oxford University Press, 103–118.

    Google Scholar 

  • Cagir, B., M. Rangraj, L. Maffuci, and B.L. Herz (1994), The learning curve for laparoscopic cholecystectomy, Journal of Laparoendoscopical Surgery 4, 419–427.

    Article  Google Scholar 

  • Clade, Harald (2002), Krankenhausfinanzierung — Falscher Ansatz mit Kostenwirkungen, Deutsches Ärzteblatt 99, 2450.

    Google Scholar 

  • Clade, Harald (2003a), Krankenhäuser: Krankenkassen befürchten enormen Kostenschub, Deutsches Ärzteblatt 100, 1843–1844.

    Google Scholar 

  • Clade, Harald (2003b), Krankenhäuser: „Lernendes“ System, Deutsches Äzteblatt 100, 2681.

    Google Scholar 

  • Clade, Harald (2004), Krankenhäuser: Länderfinanzierung vor dem Aus, Deutsches Äzteblatt 101, 227–228.

    Google Scholar 

  • Coenenberg, Adolf (2003), Kostenrechnung und Kostenanalyse, Fifth Edition, Stuttgart: Schäffer-Poeschel.

    Google Scholar 

  • Conrad, Claudia and Michael Monka (2003), Der DRG-Methoden-Pretest: Startschuss mit (Neben-) Wirkungen, in Arnold, Michael, Jürgen Klauber, and Henner Schellschmidt (eds.), Krankenhaus-Report 2002, Schwerpunkt: Krankenhaus im Wettbewerb, Stuttgart: Schattauer-Verlag, 245–256.

    Google Scholar 

  • Cromwell, J., J. Mitchell, and W. Statson (1990), Learning by doing in CABG surgery, Medical Care 28, 6–18.

    Article  Google Scholar 

  • Davidson, Russel and James MacKinnon (1993), Estimation and Inference in Econometrics, Oxford: Oxford University Press.

    Google Scholar 

  • Degener-Hencke, Udo (2003), Behutsame Öffnung der Krankenhäuser für die ambulante Versorgung, führen und wirtschaften im Krankenhaus 20, 329–334.

    Google Scholar 

  • Deutsche Krankenhausgesellschaft (2002), Spitzenverbände der Krankenkasse (GKV), Verband der privaten Krankenversicherungen (PKV), Kalkulation von Fallkosten — Handbuch zur Anwendung in Krankenhäusern.

  • Dranove, David (1987), Rate-Setting by Diagnosis Related Groups and Hospital Specialization, Rand Journal of Economics 18, 417–427.

    Article  Google Scholar 

  • Eichhorn, Siegfried (1994), Referentenentwurf zur BPflV 1995, Krankenhausökonomische Bewertung, führen und wirtschaften im Krankenhaus 11, 94–99.

    Google Scholar 

  • Ellis, Randall (1998), Creaming, Skimping and Dumping: Provider Competition on the intensive and extensive Margins, Journal of Health Economics 17, 537–555.

    Article  Google Scholar 

  • Ernst, Christian (2000), Krankenhaus-Controlling und monetäre Aries für leitende Ärzte — eine agency-theoretische Analyse, Wiesbaden: Gabler.

    Book  Google Scholar 

  • Ernst, Christian, Guenther Ernst, and Andrea Szczesny (2003), Does Learning matter for Knee Replacement Surgeries? Data Evidence from a German Hospital, Financial Accountability and Management 19, 375–396.

    Article  Google Scholar 

  • European Union Hernia Trialists Collaboration (2000), Laparoscopic compared with open methods of groin hernia repair: systematic review of randomized controlled trials, British Journal of Surgery 87, 860–867.

    Article  Google Scholar 

  • Ewert, Ralf and Alfred Wagenhofer (2002), Interne Unternehmensrechnung, Fifth Edition, Berlin a.o.: Springer Verlag.

    Google Scholar 

  • Finkler, Steven (1986), The Learning Curve Effect, Hospital Cost Accounting Advisor 1, 4–7.

    Google Scholar 

  • Finkler, Steven (1994), The Distinction between Costs and Charges, in Finkler, Steven (ed.), Issues in Cost Accounting for Health Care Organizations, Gaithersburg: Aspen Publishers, 81–93.

    Google Scholar 

  • Finkler, Steven and David Ward (1999), Essentials of Cost Accounting for Health Care Organizations: Concepts and Applications, Second Edition, Gaithersburg: Aspen Publishers.

    Google Scholar 

  • Gandjour, Afschin, C. Günster, Jürgen Klauber, and Karl Lauterbach (2002), Mindestmengen in der stationären Versorgung. Bundesweite Analyse ausgewählter Interventionen und Forschungsbedarf, in Arnold, Michael, Jürgen Klauber, and Henner Schellschmidt (eds.), Krankenhaus-Report 2002, Schwerpunkt: Krankenhaus im Wettbewerb, Stuttgart: Schattauer-Verlag, 189–201.

    Google Scholar 

  • Gibbs, Verna and Andrew Auerbach (2001), Learning Curves for New Procedures — the Case of Laparoscopic Cholecystectomy, in Shojania, Kaveh, Bradford Duncan, Kathryn McDonald, and Robert Wachter (eds.), Agency for Healthcare Research and Quality, Making Health Care Safer, Evidence Report/Technology Assessment No. 43, 213–220.

  • Graves, Nicholas, Damien Walker, Rosalind Raine, Andrew Hutchings, and Jennifer A. Roberts (2002), Cost data for individual patients included in clinical studies: no amount of statistical analysis can compensate for inadequate costing methods, Health Economics 11, 735–739.

    Article  Google Scholar 

  • Grimes, David (1993), Technology follies: The uncritical acceptance of medical innovation, Journal of the American Medical Association 269, 3030–3033.

    Article  Google Scholar 

  • Guttierriez, Benjamin, Steven Culler, and Debbie Freund (1998), Does Hospital Procedure-Specific Volume Affect Treatment Costs? A National Study of Knee Replacement Surgery, Health Services Research 33, 489–511.

    Google Scholar 

  • Haberstock, Lothar (1998), Kostenrechnung II — (Grenz-) Plankostenrechnung, Eighths Edition, Berlin: E. Schmidt.

    Google Scholar 

  • Halm, Ethan, Clara Lee, and Mark Chassin (2002), Is Volume Related to Outcome in Health Care? A Systematic Review and Methodological Critique of the Literature, Annals of Internal Medicine 137, 511–520.

    Article  Google Scholar 

  • Hall, John and Jane Hall (1996), ASA status and age predict adverse events after abdominal surgery, Journal of Quality in Clinical Practice 16, 1083–1088.

    Google Scholar 

  • Hansen, Dieter and Jörg Braun (2003), Unterfinanzierung der Intensivmedizin im deutschen DRG-System, führen und wirtschaften im Krankenhaus 20, 156–160.

    Google Scholar 

  • Heckman, James (1976), The common structure of statistical models of truncation, sample selection and limited dependent variables and a simple estimator for such models, The Annals of Economic and Social Measurement 5, 475–492.

    Google Scholar 

  • Heckman, James (1979), Sample selection bias as a specification error, Econometrica 47, 153–151.

    Article  Google Scholar 

  • Hildebrandt, Helmut and Hildegard Hesselmann (2003), Integrierte Versorgung- die Politik macht Ernst, und die Krankenhäuser müssen rasch handeln, führen und wirtschaften im Krankenhaus 20, 437–441.

    Google Scholar 

  • Hirsch, Werner (1952), Manufacturing Progress Functions, Review of Economics and Statistics 34, 143–155.

    Article  Google Scholar 

  • Hirsch, Werner (1956), Firm Progress Ratios, Econometrica 24, 136–143.

    Article  Google Scholar 

  • Institute of Medicine (2000), Interpreting the VOR in the Context of Healthcare Quality: Workshop Summary, in Hewit, Maria (ed.), Interpreting the Volume-Outcome Relationship in the Context of Health Care Quality. Washington DC: Institute of medicine; 2000 at: http://books.nap.edu/html/volume_outcome.

    Google Scholar 

  • Jachertz, Norbert and Samir Rabata (2004), Gemeinsamer Bundesausschuss: Bewährungsprobe für die Selbstverwaltung, Deutsches Ärzteblatt 101, 143.

    Google Scholar 

  • Jung, Karl (2003), Institut für Qualität und Wirtschaftlichkeit — Der Teufel steckt im Detail, Deutsches Ärzteblatt 100, 2266–2267.

    Google Scholar 

  • Kalish, R. L., J. Daley, C. C. Duncan, R. B. Davis, G. A. Coffman, and L. I. Iezzoni (1995), Costs of potential complications of care for major surgery patients, American Journal of Medical Quality 10, 48–54.

    Article  Google Scholar 

  • Kesteloot, Katrien and Freddy Penninckx (1993), The costs and effects of open versus laparoscopic cholecystectomies, Health Economics 2, 303–312.

    Article  Google Scholar 

  • Koperna, Thomas (2003), How long do we need teaching in the operating room? The true costs of achieving surgical routine, Langenbecks Archives of Surgery, published ahead of print on Oct 14, 2003 under http://www.springerlink.com/media/43wnugytrrvcex22ta5x/Contributions/1/R/U/8/1RU862RCPPXWTD1L_html/fulltext.html.

  • Legorreta, Antonio, Jeffrey Silber, George Costantino, R. W. Kobylinski, and S. L. Zatz (1993), Increased cholecystectomy rate after the introduction of laparoscopic cholecystectomy, Journal of the American Medical Association 270, 1429–1432.

    Article  Google Scholar 

  • Lauterbach, Karl and Michael Arnold (1995), Über die Vor- und Nachteile einer leistungsbezogenen Vergütung der stationären Versorgung, Lehren aus den USA für das deutsche Krankenhaus, in Arnold, Michael and Dieter Paffrath, Krankenhaus-Report 95, 167–175.

    Google Scholar 

  • Lauterbach, Karl and Marcus Lüngen (2002a), DRG-Fallpauschalen: Eine Einführung, Stuttgart: Schattauer.

    Google Scholar 

  • Lauterbach, Karl and Markus Lüngen (2002b), Wandel der Krankenhausfinanzierung, Betriebswirtschaftliche Forschung und Praxis 54, 419–431.

    Google Scholar 

  • Laycock, William, Andrea Siewers, and Christian Birkmeyer (2000), Variations in the use of laparoscopic cholecystectomy for elderly patients with acute cholecystitis, Archives of Surgery 135, 457–462.

    Article  Google Scholar 

  • Luks, François I., Judy Logan, Christopher K. Breuer, Arlet G. Kurkchubasche, Conrad W. Wesselhoeft, and Thomas F. Tracy (1999), Cost-effectiveness of laparoscopy in children, Archives of Pediatric & Adolescent Medicine 153, 965–968.

    Article  Google Scholar 

  • Malhotra, Victor (1998), Nuts and bolts in OR-Management, American Society of Anesthesiology: Annual Refresher Course Lectures 225, 1–5.

    Google Scholar 

  • McClellan, M. (1997), Hospital Reimbursement Incentives: An Empirical Analysis, Journal of Economics & Management Strategy 6, 91–128.

    Article  Google Scholar 

  • McKellar, D., R. Johnson, and J. Dutro (1995), Cost-effectiveness of laparoscopic cholecystectomy, Surgical Endoscopy 9, 158–162.

    Article  Google Scholar 

  • Meyer, Manfred and Anjy Harfner (1999), Spezialisierung und Kooperation als Strukturoptionen für deutsche Krankenhäuser im Lichte computergestützter Modellrechnungen, Zeitschrift für Betriebswirtschaft, Ergänzungsheft 5/99, 147–165.

    Google Scholar 

  • Meyer, Manfred (1996), Das optimale Fallklassenprogramm eines Krankenhauses, führen und wirtschaften im Krankenhaus 13, 14–18.

    Google Scholar 

  • Neumann, Herbert and Andreas Hellwig (2002), Das Ende der Barmherzigkeit der Intransparenz, Deutsches Äzteblatt 99, 3387–3391.

    Google Scholar 

  • Nikula, Rolf (1999), Organizational learning within health care organizations, International Journal of Medical Informatics 56, 61–66.

    Article  Google Scholar 

  • Noreen, Eric and Naomi Soderstrom (1994), Are Overhead Costs strictly proportional to Activity? Evidence from Hospital Service Departments, Journal of Accounting & Economics 17, 255–278.

    Article  Google Scholar 

  • Noreen, Eric and Naomi Soderstrom (1997), The Accuracy of Proportional Cost Models: Evidence from Hospital Service Departments, Review of Accounting Studies 2, 89–114.

    Article  Google Scholar 

  • Oberender, Peter (2003), Privates Kapital ist für öffentliche Kliniken eine ökonomische Notwendigkeit, führen und wirtschaften im Krankenhaus 20, 582–584.

    Google Scholar 

  • O.V. (2004), Fallpauschalenkatalog 2005: Besser, aber nicht optimal. Der Fallpauschalenkatalog 2005 liegt vor. Zehn Experten aus allen Trägerstrukturen haben f&w vier Fragen beantwortet, führen und wirtschaften im Krankenhaus 21, 553–558.

    Google Scholar 

  • Paffrath, Dieter (2001), Wie können wettbewerbliche Anreize bei der DRG-Weiterentwicklung implementiert werden?, in Arnold, Michael, Martin Litsch, and Henner Schellschmidt (eds.), Krankenhaus-Report 2000 — Schwerpunkt: Vergütungsreform mit DRGs, Stuttgart: Schattauer-Verlag, 267–284.

    Google Scholar 

  • Phillips, Kathryn and Harold Luft (1997), The Policy Implications of Using Hospital and Physician Volumes as „Indicators” of Quality of Care in a Changing Health Care Environment, International Journal for Quality in Health Care 9, 341–348.

    Google Scholar 

  • Piano, G., L. B. Schwartz, L. Foster, H. S. Bassiouny, J. F. McKinsey, D. Rosenthal, and B. L. Gewertz (1998), Assessing Outcomes, Costs, and Benefits of Emerging Technology for Minimally Invasive Saphenous Vein In Situ Distal Arterial Bypasses, Archives of Surgery 133, 613–618.

    Article  Google Scholar 

  • Purschke, Reinhard (1995), Optimierung der Ablauforganisation im OP, führen und wirtschaften im Krankenhaus 12, 440–443.

    Google Scholar 

  • Prause, G., B. Ratzenhofer-Comenda, G. Pierer, F. Smolle-Juttner, H. Glanzer, and J. Smolle (1997), Can ASA grade or Goldman’s cardiac risk index predict perioperative mortality? A study of 16,227 patients, Anaesthesia 52, 203–206.

    Article  Google Scholar 

  • Ramsay, Craig R., Adrian M. Grant, Sheila A. Wallace, Paul H. Garthwaite, Andrew F. Monk, and Ian T. Russell (2000), Assessment of the Learning Curve in Health Technologies, International Journal of Technology Assessment in Health Care 16, 1095–1106.

    Article  Google Scholar 

  • Reddy V. S., H. H. Phan, J. A. O’Neill, W. W. Neblett, J. B. Pietsch, W. M. Morgan, and R. Cywes (2001), Laparoscopic versus open splenectomy in the pediatric population: a contemporary single-center experience, American Surgeon 67, 859–863.

    Google Scholar 

  • Reinecke, Holger, Holger Bunzemeier, Günter Breithardt, Hans H. Scheld, and Norbert Roeder (2003), Krankenhäuser/Fallpauschalen: Schlecht abgebildet, nicht abgebildet und überhaupt nicht abbildbar, Deutsches Ärzteblatt 100, 34–35.

    Google Scholar 

  • Richter-Kuhlmann, Eva (2003), Chefärzte: Ärztliche Manager gefragt, Deutsches Ärzteblatt 100, 1417.

    Google Scholar 

  • Riemer-Hommel, Petra (1999), Selektive Verträge in der Krankenversorgung — Chancen und Risiken, Zeitschrift für Betriebswirtschaft, Ergänzungsheft 5/99, 81–93.

    Google Scholar 

  • Roeder, Norbert and Bernhard Rochell (2001), Im DRG-System schreibt der Arzt mit der Kodierung die Rechnung, führen und wirtschaften im Krankenhaus 18, 162–168.

    Google Scholar 

  • Roeder, Norbert and Jens Schick (2002), Vorbereitung der deutschen Krankenhäuser auf die DRG-Einführung, das Krankenhaus 94, 39–44.

    Google Scholar 

  • Rompel, Rainer (2003), Es wäre ein Fehler sich am bestehenden Katalog zu messen, führen und wirtschaften im Krankenhaus 20, 220–221.

    Google Scholar 

  • Rosenow, Christiane and Anke Steinberg (2002), Statistische Krankenhausdaten: Grund und Kostendaten der Krankenhäuser im Vergleich, in Arnold, Michael, Jürgen Klauber, and Henner Schellschmidt (eds.), Krankenhaus-Report 2002, Schwerpunkt: Krankenhaus im Wettbewerb, Stuttgart: Schattauer, 259–276.

    Google Scholar 

  • Russell, Ian (1995), Evaluating new surgical procedures, British Medical Journal 311, 1243–1244.

    Article  Google Scholar 

  • Russell, John, Stephen Walsh, Lori Reed-Fourquet, A. Mattie, and J. Lynch (1998), Symptomatic Cholelithiasis: A Different Disease in Men?, Annals of Surgery 227, 195–200.

    Article  Google Scholar 

  • Sangha, Oliver (2001), Begleitende Strukturmaßnahmen eines DRG-Vergütungssystems in Deutschland, in Arnold, Michael, Jürgen Klauber, and Henner Schellschmidt (eds.), Krankenhaus-Report 2002, Schwerpunkt: Krankenhaus im Wettbewerb, Stuttgart: Schattauer, 87–97.

    Google Scholar 

  • Schleppers, A., and H.-J. Bender (2003), Zukunftsorientiertes Personalmanagement in DRG-Zeiten, Anästhesiologie & Intensivmedizin 44, 131–138.

    Google Scholar 

  • Schleppers, A., J. Sturm and H.-J. Bender (2003), Implementierung einer Geschäftsordnung für ein zentrales OP-Management, Anästhesiologie & Intensivmedizin 44, 295–303.

    Google Scholar 

  • Schneider, Dieter (1965), „Lernkurven” und ihre Bedeutung für Produktionsplanung und Kostentheorie, Schmalenbachs Zeitschrift für betriebswirtschaftliche Forschung 17, 501–515.

    Google Scholar 

  • Schöffski, Oliver and Andrea Uber (1998), Grundformen gesundheitsökonomischer Evaluation, in Schöffski, Oliver, Petra Glaser, V. D. Graf, and J.-Mattias Schulenburg (eds.), Gesundheitsökonomische Evaluation, Berlin et al.: Springer-Verlag, 69–77.

    Chapter  Google Scholar 

  • Schwing, Claus (2003), Qualitätssicherung Gelenkersatz-Schluss für 800 Krankenhäuser, Klinik Management Aktuell 83, 68–74.

    Google Scholar 

  • Searle, Anthony (1945), Productivity of labor and industry, Monthly Labor Review 61, 1132–1147.

    Google Scholar 

  • Smith, David and Jan Larsson (1989), The Impact of Learning on Cost: The Case of Heart Transplantation, Hospital & Health Services Administration 34, 85–97.

    Google Scholar 

  • Soper, Nathaniel, Michael Brunt, and Kurt Kerbl (1994), Laparoscopic general surgery, New England Journal of Medicine 330, 409–419.

    Article  Google Scholar 

  • Soot, Scott, Ninham Eshraghi, Mehrdad Farahmand, I. M. Vora, N. Pereira, R. Rananavare, and S. J. Bhatia (1999), Transition From Open to Laparoscopic Fundoplication-The Learning Curve, Archives of Surgery 134, 278–281.

    Article  Google Scholar 

  • Stata Corporation (2003), Stata Statistical Software: Release 8.0.

  • Steiner, Claudia, Erik Bass, Mark Talamini, H. A. Pitt, and E. P. Steinberg (1994), Surgical rates and operative mortality for open and laparoscopic cholecystectomy in Maryland, New England Journal of Medicine 330, 408.

    Article  Google Scholar 

  • Strehl, Rüdiger (2002), Reform bei der Chefarzt- und Hochschullehrervergütung in Krankenhäusern und Universitätsklinika, in Arnold, Michael, Jürgen Klauber, and Henner Schellschmidt (eds.), Krankenhaus-Report 2001, Stuttgart: Schattauer-Verlag, 123–131.

    Google Scholar 

  • Sturm, Roland (1999), Cost and quality trends under managed care: is there a learning curve under behavioral health carve-out plans, Journal of Health Economics 18, 593–604.

    Article  Google Scholar 

  • Treplitz, Charles (1991), The Learning Curve Deskbook, Westport: Quorum Books.

    Google Scholar 

  • Tuschen, Karl-Heinz and Michael Quaas (2001), Bundespflegesatzverordnung, Kommentar mit einer umfassenden Einführung, in Das Recht der Krankenhausfinanzierung, Fifth Edition, Stuttgart: Kohlhammer.

    Google Scholar 

  • Tuschen, Karl-Heinz and Michael Quaas (1998), Bundespflegesatzverordnung, Kommentar mit einer umfassenden Einführung in das Recht der Krankenhausfinanzierung, Fourth Edition, Stuttgart et al.: Verlag W. Kohlhammer.

    Google Scholar 

  • Warshaw, Andrew (1993), Reflections on laparoscopic surgery, Surgery 114, 629–630.

    Google Scholar 

  • Weisbrod, Burton (1991), The Health Care Quadrilemma: An Essay on technological Change, Insurance, Quality of Care, and Cost Containment, Journal of Economic Literature 29, 523–552.

    Google Scholar 

  • Welty G, E. Schippers, V. Grablowitz, A. G. Lawong, A. Tittel, and V. Schumpelick (2002), Is laparoscopic cholecystectomy a mature operative technique?, Surgical Endoscopy 16, 820–827.

    Article  Google Scholar 

  • Willeke, Frank, Monika Willeke, Ulf Hinz, Dorothea Lorenz, Kristian Nitschmann, Andreas Grauer, Norbert Senninger, Ernst Klar, and Christian Herfarth (1998), Effect of Surgeon Expertise on the Outcome in Primary Hyperparathyroidism, Archives of Surgery 133, 1066–1070.

    Article  Google Scholar 

  • Wolters, U., T. Wolf, H. Stutzer, and T. Schroder (1996), ASA classification and perioperative variables as predictors of postoperative outcome, British Journal of Anaesthesia 77, 217–222.

    Article  Google Scholar 

  • Woods, John, Robert Saywell, Allen Nyhuis, Stephen J. Jay, Rosemary G. Lohrman, and Harold G. Halbrook (1992), The Learning Curve and the Cost of Heart Transplantation, Health Services Research 27, 219–238.

    Google Scholar 

  • Wright, T. (1936), Factors affecting cost of airplanes, Journal of Aeronautical Sciences 3, 122–128.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Christian Ernst.

Additional information

We thank two anonymous referees for their detailed and helpful suggestions. In addition, many valuable comments from the participants of the German Society for Classification’s annual (2001) conference in Munich and the 2001 CIMA non-profit accounting workshop at the University of Edinburgh are gratefully acknowledged by the authors. Our special thanks goes to the anesthesiologists, surgeons and other operating room staff at ‘our’ hospital. Their willingness to grant us access to the data and broaden our horizons on numerous medical question have made this study possible. The usual disclaimer applies.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ernst, C., Szczesny, A. Cost Accounting Implications of Surgical Learning in the DRG Era — Data Evidence from a German Hospital. Schmalenbach Bus Rev 57, 127–166 (2005). https://doi.org/10.1007/BF03396712

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF03396712

JEL-Classification

Keywords

Navigation