قیمت گذاری آینده نگر بر اساس DRG و حسابداری ترکیبی __ بررسی مکانیسم های اجرای موفقیت آمیز

Escalating health care expenditures have brought on the need for restructuring health care delivery. A common response to this problem has been to seek market-based solutions. In the literature, however, increasing concern has been expressed that hospital management reforms will fail or will have only a limited impact. This longitudinal case study extends our understanding of the effects of implementing DRG-based prospective pricing and case-mix accounting systems for hospital management control in a specific health care setting. Moreover, this study contributes to current knowledge by focusing on the mechanisms explaining successful implementation of new accounting and control systems in the health care sector. A deep understanding of these mechanisms may help us to design better management control systems, and thus circumvent problems in implementing these systems. Our study suggests that successful implementation in the studied context is strongly dependent on the involvement of clinicians in this process. Integrated clinical and financial accountability, assigning responsibility for implementation to clinicians, freedom in choosing appropriate control tools, and flexibility in adoption all facilitated implementation. Furthermore, we argue that this process has also been advanced by the gradual implementation of these reforms and intensifying institutional pressures.

National health care systems have faced a dramatic increase in health care expenditures, leading many decision-makers to seek new ways for restructuring the delivery of health care services. A common response to this challenge has been to implement market-based solutions. In addition, there has also been a distinct trend towards an increased awareness and use of accounting information in health care settings (see Brunsson et al., 1998, Lapsley, 1994a, Hopwood, 1984, Paavilainen, 1999, Kekomäki, 1997 and Häkkinen, 1995). Appeals are made to the potential benefits offered by improved costing procedures, more specific criteria for resource allocation, and improved management information systems. This on-going process of change in the health care sector, and the role of accounting in this process, have been of increasing interest to researchers (e.g., Kurunmäki, 2004, Lapsley and Wright, 2004, Jacobs et al., 2004, Kurunmäki et al., 2003, Lowe, 2000, Lapsley, 1999, Doolin, 1999 and Abernethy, 1996). However, little work has focused on studying the effects of these reform projects (Lowe and Doolin, 1999 and Lapsley, 1999), and the experiences of health care professionals, managers and patients have been largely ignored until recently (Jacobs et al., 2004, Kurunmäki, 1999, Doolin, 1999 and Chua and Preston, 1994). A number of authors have noted that clinicians have had few incentives to work more efficiently, and they have had neither accountability for, nor information on the resource consumption implications of their decisions (e.g., Sanderson, 1987, Bloomfield and Coombs, 1992 and Lapsley, 2001). These factors were seen to contribute to the inefficiency of hospitals, and the DRG-based prospective payment system (PPS) was therefore designed in the U.S. to change the behaviour of hospitals by altering the economic incentives facing hospital decision-makers (Preston, 1992 and Guterman et al., 1991). Compared to retrospective payment systems, under which hospitals were reimbursed in full for costs expended in service provision, PPS introduced fixed pre-determined reimbursement rates for service packages determined based on Diagnosis-Related-Groups (DRGs).1 In those cases where actual costs exceeded the pre-determined rate, the hospitals were expected to absorb the loss. In the literature, the use of DRGs for determining hospital products has been advocated as offering hospital management the means for understanding and controlling resource usage within hospitals (e.g., Fetter and Freeman, 1986 and Fetter, 1987). It is argued that by focusing on the final products, the DRG control framework – consisting of the DRG-based prospective payment and case-mix accounting systems – allows for the efficient2 utilization of intermediate services as well as efficiency in the production of these services (Fetter and Freeman, 1986 and Fetter, 1992). Individual departments could be made responsible for the efficient production and supply of the necessary intermediate services (e.g., lab tests, treatments, medication, and nursing) required for the treatment of patients, whereas the clinicians would be responsible for determining the mix of the hospital's resources and services required to diagnose and treat each type of patient. The objectives of case-mix accounting are to provide a complete financial picture of the costs of treating individual patients, and the costs of treating different patient groups. This information could then be used in the planning, controlling and pricing of services. It is, for example, believed that it would be possible to compare hospitals’ efficiency3 in providing these services (Weiner et al., 1987, Palmer et al., 1991 and Chua, 1995), or it would allow comparisons between clinicians (Doolin, 1999). It has also been suggested that DRGs might initiate a process of self-discipline among clinicians, as they seek to perform according to industry standards (Chua and Degeling, 1993 and Doolin, 1999). The purpose of management control systems (MCSs) is to provide information that would influence employees’ behaviour towards achieving organizational goals (e.g., Merchant and Van der Stede, 2003 and Anthony and Govindarajan, 2003). Within the health care context, it has been suggested that the involvement of clinicians in resource management is critical to improve the efficiency of hospitals (Abernethy, 1996 and Abernethy and Stoelwinder, 1990; see also Doolin, 1999 and Averill and Kalison, 1991). Consequently, the failure to implement a management accounting control system has been likened to the situation in which clinicians would reject the relevance of accounting information and refuse to act on this information in performing their duties (Lapsley, 2001). We see that it would also be appropriate to compare the observed impacts to the objectives set for the system, since the objectives set for different control mechanisms may vary depending on the total control package employed (Otley, 1999). For us, ‘success’ and ‘failure’ represent the two ends of a continuum. As a result, success or failure in the implementation of MCS varies depending on the observed positive and negative effects. However, the precise positioning of the evaluation on the continuum is difficult, or even impossible. Therefore, we have to settle for more vague classifications in our evaluation attempts. Thus, we define a MCS successful, from the management's point of view, if its positive effects outweigh the negative effects. Furthermore, we see that the evaluation is time- and context-dependent, as the objectives and control needs change over time. The observed effects also represent the sum of many intertwining situational factors. Many studies have examined the effects of the DRG-based prospective payment system on costs, on operational matters, and on quality (Charpentier and Samuelson, 1996, Sumner and Moreland, 1995, Chua and Preston, 1994, Chua and Degeling, 1993, Donaldson and Magnussen, 1992, Fetter, 1991, Guterman et al., 1991, Coulam and Gaumer, 1991, Borden, 1988 and Bevan and Brazier, 1985; see also Lehtonen, 2001). It appears that the implementation of DRG-based PPS has affected the way hospitals operate. There is evidence that the average length of stay, admissions and intensity of care, and thus health care costs have, at least initially, decreased as intended. In addition to these intended effects, several dysfunctional impacts, such as DRG-creeping4 and DRG-dumping,5 have been reported. It has also been feared that the quality of patient care might be adversely affected. Despite an extensive literature suggesting that DRGs and case-mix accounting systems could enhance the management of hospitals, few studies have explored this topic empirically at the micro level; moreover, little is known about how the observed effects have actually been managed (Coulam and Gaumer, 1991). Furthermore, apart from a few exceptions (e.g., Lowe, 2000), the reported experiences in these studies have not always supported the arguments presented by those advocating DRGs. There is, nevertheless, some evidence suggesting that clinicians have not been interested in the information provided by case-mix accounting systems, and some countries have encountered considerable resistance from hospitals and medical staff to the use of DRGs for funding and controlling purposes (Weiner et al., 1987, Palmer et al., 1991, Chua and Degeling, 1993, Doolin, 1999 and Lowe and Doolin, 1999). In general, much concern has been expressed that hospital management reforms will fail or only have limited impact due to general resistance to and difficulties in their implementation (e.g., Preston et al., 1992, Covaleski et al., 1993, Lapsley, 1994a, Laughlin et al., 1994, Jones and Dewing, 1997, Pettersen, 1999, Pettersen, 2001, Doolin, 1999 and Jacobs et al., 2004). Decoupling phenomena have often been used to explain accounting failures in the health care sector (Covaleski and Dirsmith, 1983, Lapsley, 1994b, Pettersen, 1995 and Pettersen, 2001). Institutional theory predicts that another prominent path to organizational survival, in addition to being technically efficient, is to achieve legitimacy in the institutional environment by conforming to societal norms of acceptable practice (Meyer and Rowan, 1991, DiMaggio and Powell, 1991 and Scott et al., 2000). The paradox is that many of these externally directed, relatively simple symbolic displays, such as the DRG control framework, are not held to be able to faithfully represent the complexities and indeterminacies of internal operating processes (Covaleski et al., 1993). In such cases, organizations tend to avoid dysfunction by decoupling these symbolic management systems from their internal operating processes, thus avoiding their use in the management of these operations (Meyer and Rowan, 1991). Other, closely related, explanations for failure have roots in power struggles and cultural differences between different professional groups. According to Markus and Pfeffer (1983), there is a greater potential for conflict, resistance, and system failure, if the introduction of accounting and control systems shifts power relations within the organization. It has been argued that implicit in this DRG control framework is that the clinician–patient relationship is no longer impenetrable to non-expert (non-clinician) scrutiny, but subject to performance measurement and evaluations by hospital management (Chua and Degeling, 1993 and Covaleski et al., 1993). Clinicians, however, have been reluctant to have their practice scrutinized and their clinical freedom potentially infringed upon (Doolin, 1999 and Abernethy and Stoelwinder, 1995). On the other hand, it has been suggested that the compulsion to change increases the likelihood of failure (Lapsley, 2001). In the literature on DRGs and case-mix accounting, detailed attention has been given to the issues of resistance and possible harmful side-effects of these systems. Although we find these issues extremely important, we suspect that we are, however, left with a partial picture and incomplete explanations of the effects resulting from DRGs and case-mix accounting. Although drugs may cause side-effects and adverse reactions in some patients, this does not mean that all patients will experience them, or that the side-effects for them would be alike. Contingency theory argues, in a similar vein, that there is ‘no universally appropriate accounting system which applies equally to all organizations in all circumstances’ (Otley, 1980, p. 413). Furthermore, it has been claimed that too little research attention, in general, has been afforded to studying the effects of using MCSs in different contexts (Ittner and Larcker, 2001 and Otley, 2001). Many important research topics have therefore been left unexplored, conflicting results unresolved, and a consensus on the performance benefits unattained. Most of the research on the effects of DRG-based PPS has been centered in the U.S., but studies from other contexts remain relatively rare (Mikkola et al., 2001). The importance of forming fuller explanations related to DRG-based prospective payment and case-mix accounting systems is accentuated by Abernethy and Stoelwinder (1995). They argue that some form of acceptable output control will need to be implemented due to the type of market-based solutions adopted and the needs of hospitals to manage not only the means but also the end results. Extending our understanding will require empirical, in-depth studies that examine the effects of the DRG control framework in different national contexts and seek to uncover the mechanisms explaining how the observed effects are accomplished. This longitudinal case study seeks to refine and specify (Keating, 1995) existing knowledge, first, by extending our knowledge of the consequences arising from the implementation of DRG-based prospective pricing6 and case-mix accounting systems on clinical activities and the management of a hospital in a specific health care setting. We see that hospital management accounting control systems and clinical activities serve as mechanisms through which the effects of the DRG control framework are transmitted, and eventually become manifested in the clinical outcomes and observed financial performance of hospitals in macro-level studies. Second, we aim to extend our understanding of the effects of implementing new accounting and MCSs in the health care sector by focusing on conditions that may give rise to a conflict between health care professionals and hospital management, as well as on those actions that may alleviate or resolve such conflicts. Particular attention is paid to both the implementation process and institutional setting. The study was carried out in a large Finnish teaching hospital. The rest of the paper is structured as follows. Section 2 provides further details on the research method and introduces the organization studied. Section 3 reports the impacts of DRG-based accounting systems on financing, management accounting control systems, clinical activities, and perceived efficiency of the selected profit centres. At the end of each section, the observed impacts are compared with the corresponding objectives of the new control system. In the subsequent sections, we seek explanations for the mechanisms facilitating the implementation of the new system by analysing the institutional setting and the implementation process in detail. In the final section, we summarize the key findings of the paper.

In the literature, it has been suggested that the DRG-based prospective pricing and case-mix accounting systems could contribute to the management of hospitals (eg., Fetter and Freeman, 1986 and Fetter, 1987). However, few studies have examined this topic empirically at a micro level, and the reported experiences have not always favoured the implementation of these systems. Moreover, these studies have devoted much attention to describing resistance and possible harmful side-effects (Weiner et al., 1987, Doolin, 1999, Lowe and Doolin, 1999 and Pettersen, 1999). This longitudinal case study extends our understanding concerning the effects of implementing DRG-based prospective pricing and case-mix accounting systems on the management control of a hospital in a specific health care setting. The study also contributes to current knowledge by focusing on the mechanisms explaining successful implementation of new accounting and control systems in the health care sector. A deep understanding of these mechanisms can help us to design better management control systems for the health care sector and circumvent problems in their implementation. This study demonstrates that DRG-based prospective pricing and case-mix accounting systems can be successfully implemented, and that the intended effects can, for the most part, be achieved. In this particular context, it seems that municipalities have become better able to predict their health care costs. Some municipalities have even been able to compare different service providers, thereby gaining more control over the costs of specialized health care. In addition, health care professionals appear to have become cost-conscious and increasingly aware of their limited financial resources. They seemed to act in line with the expectations of the DRG control framework: there was evidence that the use of intermediate services became controlled and attempts were made to rationalize operating activities in order to become more cost-efficient. However, the role of DRG-based prospective pricing and case-mix accounting systems is not as clear cut in this control process. The relevance, applicability and use of the information provided by these systems seemed to vary between organizational levels and between individuals. At the central management level, this information was found more valuable and was more frequently used. At the lower levels of the management hierarchy, the views regarding the relevance and applicability of this patient-based revenue and cost information varied more between situations and individuals: in general, it seemed to have more potential for control purposes at the profit centre and speciality levels, but less at the departmental level. We believe that these findings can be explained by the differences in tasks and assigned accountabilities. There was also evidence of other control systems in use, and that DRG-based information was used in a complementary fashion with the information provided by these other control systems. Nonetheless, in the studied context, we witnessed no decoupling phenomenon (cf. Weiner et al., 1987 and Pettersen, 2001; see also Covaleski et al., 1993), as accounting and DRG-based information seemed to have penetrated deep into the organization. In the literature, it has been suggested that health care management reforms fail due to conflicts between health care professionals and hospital management (Doolin, 1999, Abernethy and Stoelwinder, 1995 and Weiner et al., 1987). We argue that the key to successful implementation is an ability to persuade clinicians to become centrally involved in the management and the development of the control systems. We argue that integrating clinical and financial accountability, and assigning responsibility for the implementation to clinicians have served this purpose in our case study context. Moreover, the freedom of choice and flexibility in adoption seem to have alleviated conflicts and settled disputes, and thereby enhanced the co-operation of clinicians. Furthermore, we believe that the gradual implementation of these reforms and the intensifying institutional pressures have also fostered the adoption and implementation of DRG-based accounting systems, though they were not sufficient alone to explain the decision to implement, nor the success of this implementation. In this study, we have focused on one specific management control system, the DRG control framework, and examined whether this system has fulfilled the expectations set for it from the point of view of the management of the case study organization. However, it is recognized that management control is exercised simultaneously through many different formal and informal control systems. In addition to the DRG control framework, we observed a number of other control systems in the case organization, and there seemed to be differences in their use between organizational levels. Thus, we believe that future research would benefit from broadening the scope, and focusing on the roles and interrelationships of various control systems in the control package. This is important because we believe that sometimes the desired outcome could be achieved by substituting control systems, while other occasions may require that the control systems be used in a reinforcing way.