We conducted negotiated interactive observation that is suggested by Wind as the most appropriate way to conduct ethnographic fieldwork in hospital settings (Wind, 2008, 79-89). With permission from the head of the Clinic, we were allowed to interview and follow doctors, talk to, and observe administrators in the office where they work, inquire nurses about their administrative activities and observe them while sitting in the nurses’ station at the computer. During this time, we were able to watch patients interacting with the staff of the Clinic and heard several stories about patients and their administration.
Based on our observations we can describe the way patients first became numbers and codes – and finally cash, as they followed their path in the administrative machinery of the Clinic.
The patients enter the neoclassical building of the Clinic through its imposing entrance. Right after the gates they face the reception window where they have to check in. The administrator at the other side of the window types their personal data into the computer, and from then on the patient cannot leave the hospital without her1 file having closed; ready to be sent to the National Health Insurance Found for reimbursement.
“Everyone, even the doctor knows that where the administrative records are handled well, a control is effective, which is why we [the doctors] have this conscious aversion to administration. That is why there are strict rules, which force the doctors to fulfill their administrative tasks. So when the patient first comes in, the doorkeeper is made to send her to this window [of administration]. Here, she has to give all of her important personal data and from then on the physician has no other choice but to keep her records” (Physician #1: Head physician at the Clinic).
From that point, the patient exists in two parallel universes. In one of them she is present with her bodily self, laying in a hospital bed, eating the not-so-great hospital meal, receiving medical interventions and pharmaceuticals. In the other one, she is classified into diagnostic categories, attached with intervention codes; her stay and medicine consumption is recorded.
Patients are not aware of the codes they represent in the hospital’s financing system. Mr X is suffering from hernia, which appears to be one of the most ordinary medical problems in the eyes of the medical staff. His condition was documented, an ECG test and some other tests were performed, he has signed that he consented to the operation. He is waiting for the operation right now. His case is considered as a simple and obvious one, the documentation of which does not require many special knowledge.
Mrs Y on the other hand is lying in the intensive-care unit (ICU). She went through a very difficult surgery that removed a tumor from her pancreas. Her documentation represents a much more difficult task than Mr X’s. While the hospital receives considerably more money after a patient with the same diagnosis/intervention, if she was kept in the ICU, the administration of such cases is much more complex; the performed procedures that justify the medical necessity of the ICU use have to be reported: “This way I can prove that she was not only staying in ICU to bring more money to the hospital, but some medical interventions were necessary that only in ICU could be performed, like mechanical ventilation, or invasive CVP (continuous measurement of superior vena cava pressure)” (Physician #3: Mrs Y’s surgeon).
The minimum length of the stay is also determined (min. 36 hours), so patients cannot be observed in the ICU for only a few hours, just to become eligible for the extra money. The DRG system was made stricter in this sense, as the National Health Insurance Fund (NHIF) had suspected the frequent misuse of these codes. Our interviewees at the Clinic acknowledged that at the beginning the reported DRG codes did not always faithfully match the reality, because this was how they could maximize profit, but in the case of the ICU, “it was out of question, as the Unit has always been so overloaded, that it was never possible to rest patients there just to get some extra profit, even if we wished to” (Physician #4: Surgeon at the Clinic).
The documentation has been complicated in several other ways since the introduction of DRG in order to prevent ‘cheating’. The optimal length of stay with each diagnosis/intervention has been also defined, but there are always ways to evade these rules. Mr Z, a patient who underwent laparoscopic gallbladder surgery two days ago, for example, packing and leaving today on his own risk, but according to the documentation he is staying for one more night.
On the other hand, there are cases, when a physician would keep the patient for longer if it was up to him, but the patient has to be discharged based on the DRG expectations. There is an optimal length of hospital stay for each illness/intervention in terms of DRG reimbursement, thus it is not profitable to keep the patient longer, or shorter than that.
The software running to process all these data was originally designed for the documentation of motor vehicle service stations – according to an urban legend. Hence it has no sensitivity for the human factor. What is true, that this software, as any other computer program, has fixed categories and an inflexible structure. This means that each unique case has to be inserted, sometimes forced into this structure. At the same time, in order to be able to do this, one has to learn the structure of the classificatory system. “If you are not familiar with the classification system, you will never find the category you are looking for” (Physician #5: Ward physician). Each hospital has a different way to fulfill these administrative tasks. In the Clinic, it is done by the ward physicians, who have to make the documentation of every patient of the wards, while accomplishing heavy workloads. There is no extra time allocated for this work. A peculiarity of the Hungarian healthcare system is that the higher rank physicians are eager to undertake less complicated, even routine cases (which in other health care system would be done by residents or young physicians) expecting informal payment (Gaal, 2006, 86-102). This is the only reason why – in the overloaded Hungarian health system – the young ward physicians can still find some time for all of the documentation chores. In theory each physician should make the documentation of his own patients, but in fact the young ward physician is the one who is actually sitting at the computer with a pile of medical charts and entering the codes. There are also administrators working in the hospital, whose main job is the documentation of the patients’ admission, but sometimes they also help the physicians with data input.
The most important person, in terms of DRG coding in the Clinic, is one surgeon, who had been involved from the beginning on in the Hungarian DRG development. He is appointed to monitor the complete data set; to fill up every missing piece of data and to revise the whole recording. At the end, every patient’s data is concentrated in his hands.
“Each doctor has to leave the medical charts and records of his patient in the admission office when the patient leaves. I have a computer there, where I review the whole documentation. On the one hand I look through if there is any mistake in terms of formal requirements – there are very complex formal requirements. (The NHIF always sets new requirements, and if they are not met, the whole documentation cannot be submitted and [the hospitals] are not reimbursed.) On the other hand, I also have to review whether the medical charts and the computer entries match and whether the codes are for the most optimal reimbursement. Sometimes I have to revise certain codes, or have to add additional codes” (Physician #2: Surgeon controlling the DRG in the Clinic).
For the outside bystander it appears that this surgeon would carry alone the responsibility of the DRG coding of the whole Clinic. To the question, why he is willing to do this, he says: “Simply put, I have been working in this Clinic for more than 26 years now, and I don’t want it to go to ruin, I want it to operate. And since I know DRG, I do everything what I can. The rest of the employees do not, or do not want to understand the DRG. I don’t care. I know it, so I review their coding, or do the coding forthem. That’s it” (Physician #2: Surgeon controlling the DRG in the Clinic).
When a new resident arrives, this surgeon is the one who takes time to explain the rules of the coding. On his first days, the resident has to learn to use the software; he is shown what has to be entered where. He is told what the most important aspects he has to keep in mind; the most frequent mistakes are highlighted. He is followed to the ICU for example, and his coding practice is observed there for a while. According to the appointed surgeon, however, there are too many new rules and changes, which makes unrealistic to expect the physicians to follow all of them.
“I am fed up with explaining every stupid alteration all the time. I also believe it wouldn’t be their job to follow all these rules. And it would be just too much time to explain them over and over again. I rather just do it myself for them. It takes less time this way” (Physician #2: Surgeon controlling the DRG in the Clinic).
After the Clinic finished its review, the Medical University’s controlling team reviews the coding again for a last time. The University has a contract with one of the most prestigious auditing companies, according to which the company’s job is to get the most reimbursement out of the achieved performance. The auditing company receives premium based on the extra money their re-coding realizes for the University.
The appointed surgeon who does the DRG review at the Clinic can also learn from these re-codings. He studies the changes the auditing company has made and next time he uses these ‘smart codings’. His position would allow him to report on the errors and malfunctions of the system, but– as he complains – there are no standardized ways to give feedback. Luckily, his superior too was highly involved in the development of DRG, and still has some formal and informal connections to the maintainers of the system at the NHIS. Through this head physician he can channel his observations, but they both have doubts whether these comments are taken into consideration at all at the end.
ERÖSS Gábor, FERNEZELYI Bori, KOLTAI Júlia & LEVENDEL Sára (2010), From the Engagement to the Divorce of Knowledge and Policy – DRG: a knowledge-based regulatory instrument in the Hungarian health sector.