Computerized Medico-Economic Decision Making: An International Comparison

  • P. Landais
  • T. Boudemaghe
  • C. Suehs
  • G. Dedet
  • C. Lebihan-Benjamin
Part of the Health Informatics book series (HI)


A large part of public health care costs come from hospital expenditures. Activity-based payment has gradually become the most common system for hospital reimbursement in high income countries. It was variously implemented over the last decade in order to achieve shared goals such as improving overall efficiency, quality or transparency, and to help in hospital management. Activity-based funding is also supposed to help targeting where and how money is being spent, and thus orient policy and decisions on the behalf of patients. The system also provides for payment adjustments and promotes high quality of care via reward payments.

Different schemes have been adapted to each country according to their individual developmental contexts, or to their conception of a welfare state. Variations relate to differences in the health system models used, the relationships between providers and funders, the degree of centralization, the separation between purchasing and provision, the structure of the hospital market, the type of facilities, or the level of competition between public and private structures.

European countries have adopted rather different regulation and monitoring of health expenditure. To better understand the international complexity of the framework we recalled the basic principles of activity-based payment. We then explored the context of development of activity based payment in five countries: United States, Australia, the United Kingdom, France and Germany. We also described the diagnosis related groups they are based upon, the basis of setting up costs and tariffs, the fields of application, and the regulatory mechanisms.


Activity-based payment Health planning Hospital funding Hospital expenditures Hospital performance Diagnosis related groups Pricing activity International policies Decision making 


  1. Australian Government (eds) (2010) A national health and hospitals network for Australia’s future. Publications number: P3-6430. Commonwealth of Australia pp 1–74Google Scholar
  2. Busse R, Riesberg A (2004) Health care systems in transition: Germany. Copenhagen, WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies Vol 6, No 9Google Scholar
  3. Busse R, Geissler A, Quentin W, Wiley MM (eds) (2011) Diagnosis related groups in Europe: moving towards transparency, efficiency and quality in hospitals. Open University Press/McGraw-Hill, Maidenhead, p 458Google Scholar
  4. Cash R, Grignon M, Polton D (2003) L’expérience américaine et la réforme de la tarification hospitalière en France – commentaire de l’article de J Newhouse. Economie publique 13:35–47Google Scholar
  5. Commission des comptes de la sécurité sociale (eds) (2009) Comparaison internationale des dispositifs de fixation des tarifs d’activité des établissements de santé pp 142–145Google Scholar
  6. Cylus J, Irwin R (2010) The challenges of hospital payment systems. Eur Obs 12(Autumn):1–3Google Scholar
  7. Dexia and HOPE (2008) Hospitals in the 27 member states of the European union. Dexia Editions, FranceGoogle Scholar
  8. DREES (eds) (2009) Second rapport d’activité du Comité d’évaluation de la T2A. Document de travail No 94Google Scholar
  9. Ellis R, Vidal-Fernandez M (2007). Activity-based payments and reforms of the English hospital payment system. Health Econ Policy Law 0:1–10Google Scholar
  10. Ettelt S, McKee M et al (2009) Investing in hospitals of the future In: Rechel B, Wright S, Edwards N, Dowdeswell B, McKee M (eds) European Observatory on health systems and policies. Observatory studies series No 16Google Scholar
  11. Farrar S, Sutton M, Chalkley M et al (2009) Has payment by results affected the way that English hospitals provide care? Difference-in-differences analysis. BMJ 339:1–8CrossRefGoogle Scholar
  12. Fürstenberg T, Zich K et al (2010) G-DRG-Impact evaluation according to sec. 17b para.8 Hospital Finance Act. Final report of the first research cycle (2004–2006) German Institute for the Hospital Remuneration System (InEK) (eds) pp 1–13Google Scholar
  13. Hensen P, Beissert S et al (2008) Introduction of diagnosis-related groups in Germany: evaluation of impact on in-patient care in a dermatological setting. Eur J Publ Health 18:85–91CrossRefGoogle Scholar
  14. Herwartz H, Strumann C (2012) On the effect of prospective payment on local hospital competition in Germany. Health Care Manag Sci 15(1):48–62PubMedCrossRefGoogle Scholar
  15. IRDES (eds) (2009) Principes et enjeux de la tarification à l’activité à l’hôpital (T2A). Enseignements de la théorie économique et des expériences étrangères. Document de travail. DT No 23, pp 1–29Google Scholar
  16. Langenbrunner JC, Cashin C, O’Dougherty S (eds) (2009) Designing and implementing provider payment systems. How-to manuals. World Bank, Washington, DCGoogle Scholar
  17. Mason A, Smith PC (2006) Regulation and relations between the different participants in the English health care system. Revue Française des Affaires Sociales 2:265–284Google Scholar
  18. Ministère de la santé et des sports (ed) (2010) Rapport 2010 au Parlement sur la tarification à l’activité (T2A) pp 1–56Google Scholar
  19. Miraldo M, Goddard M, Smith P (2006) The incentive effects of payment by results, CHE research paper 19. Centre for Health Economics, University of YorkGoogle Scholar
  20. Neubauer G, Pfister F (2008) DRGs in Germany: introduction of a comprehensive prospective DRG payment system by 2009. In: Kimberly JR, de Pouvourville G, D’Aunno T (eds) The globalization of managerial innovation in health care. Cambridge University Press, New-York, pp 153–175Google Scholar
  21. O’Reilly J, Busse R et al (2012) Paying for hospital care: the experience with implementing activity-based funding in five European countries. Health Econ Policy Law 7(1):73–101PubMedCrossRefGoogle Scholar
  22. Or Z (2010) Activity based payment in hospitals: evaluation. Health Policy Monitor. Available at:
  23. Or Z, Häkkinen U (2012) Qualité des soins et T2A : pour le meilleur ou pour le pire ? IRDES Paris. DT No 53, pp 1–20Google Scholar
  24. Paris V, Devaux M, Wei L (2010) Health systems institutional characteristics: a survey of 29 OECD countries. OECD health working papers No 50, OECD PublGoogle Scholar
  25. Rosenthal MB, Landon BE et al (2006) Pay for performance in commercial HMOs. N Engl J Med 355(18):1895–1902PubMedCrossRefGoogle Scholar
  26. Scheller-Kreinsen D, Geissler A, Busse R (2009) The ABC of DRGs. Eur Obs 11(4):1–5Google Scholar
  27. Street A, Maynard A (2007) Activity based financing in England: the need for continual refinement of payment by results. Health Economics, Policy and Law 2(Pt 4):419–427Google Scholar
  28. Street A, O’Reilly J, Ward P, Mason A, Street A, O’Reilly J, Ward P, Mason A (2011) DRG-based hospital payment and efficiency: theory, evidence, and challenges. In: Busse R, Geissler A, Quentin W, Wiley M (eds) Diagnosis related groups in Europe. Moving towards transparency, efficiency and quality in hospitals. Open University Press, Maidenhead, pp 93–114Google Scholar
  29. Sussex J, Farrar S, PbR team (2008) Payment by results. Evaluation newsletter 3. Office of Health Economics, LondonGoogle Scholar
  30. Vogl M (2013) Improving patient-level costing in the English and the German ‘DRG’ system. Health Policy 109:290–300PubMedCrossRefGoogle Scholar
  31. Wiley M (2011) From the origins of DRGs to their implementation in Europe Diagnosis Related Groups in Europe – moving towards transparency, efficiency and quality in hospitals. In: Busse R, Geissler A, Quentin W, Wiley M (eds) Diagnosis-Related Groups in Europe: moving towards transparency, efficiency and quality in hospitals. Mc Graw Hill, Copenhagen, pp 3–8Google Scholar

Copyright information

© Springer-Verlag France 2014

Authors and Affiliations

  • P. Landais
    • 1
  • T. Boudemaghe
    • 2
  • C. Suehs
    • 2
  • G. Dedet
    • 3
  • C. Lebihan-Benjamin
    • 4
  1. 1.Département de Santé Publique, BESPIM, CHU de Nîmes, Hôpital CarémeauMontpellier 1 University & CHU de NîmesNîmesFrance
  2. 2.CHU de Nîmes, Département de Santé Publique, BESPIMCHU de Nîmes, Hôpital CarémeauNîmesFrance
  3. 3.London School of Hygiene and Tropical Medicine, London School of Hygiene and Tropical MedicineLondonUK
  4. 4.Institut National du Cancer, Pôle Santé Publique et Soins, Département Observation, Veille, ÉvaluationInstitut National du CancerBoulogne BillancourtFrance

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