Two ophthalmology departments financed by compulsory health insurance: what is it that makes a difference in costs and clinical effectiveness?

AIM To identify factors contributing to significant differences between two university hospital departments of ophthalmology, one in Paris, France, and the other in Zagreb, Croatia, in their clinical effectiveness and cost-efficiency. METHOD Structural, clinical, and financial characteristics of a Croatian and French ophthalmology department were compared for the 1996-2000 period. We used Paris ophthalmology department reports from 1996-2000 period as data source. Data on the Zagreb department performance for the same time period were obtained from the financial department. After comparative analysis of performance to show consistency and comparability of the two departments according to the type and prevalence of pathology, case-mix, and approaches to therapeutic, educational, and research activities, hospital budget analysis was performed, with special reference to the length of hospital stay according to diagnosis, number of examinations, material expenses, salaries, and investment. The variables analyzed were the number of emergency, regular, and hospitalized patients; number of physicians; number and type of surgical procedures; number of patients and length of hospital stay according to diagnosis; hospital budget distribution; and usage of hospital beds. RESULTS Although the structure, technology, level of education, organization, and patient profile at the two departments were similar, the mean number of operative procedures per specialist per year was different (109.4 for Zagreb vs 199.2 for Paris). Hospital bed occupancy was 99.4% in Zagreb and 74.9% in Paris. The mean duration of hospital stay was 7.5 days in Zagreb and 2.2 days in Paris. Zagreb had considerably longer hospital stay for all diagnoses except severe infections. Zagreb had lower investment in new technologies (0.4%) than Paris (20.1%), and higher material expenses (33.2% vs 10.1%, respectively). CONCLUSION Different instruments of hospital services payment result in different clinical and organizational behavior of the hospital personnel and management. The three-fold longer stay in Zagreb can be explained by the mechanism of service payment, which is based on payment for capacity and structure and process in Zagreb instead of payment for service and service-related outcomes in Paris. Comparison of the two departments indicates that clinical efficiency and effectiveness cannot and should not be separated from financial incentives that can stimulate (Paris) or discourage (Zagreb) rational and evidence-based clinical behavior.