Ethical perceptions of DRG-based hospital financing among physicians and hospital managers in Germany : a cross-sectional survey

Background: Diagnosis-Related Groups (DRGs) have reshaped German hospital financing by linking reimbursement to case-based payment. While intended to increase efficiency, DRG-based reimbursement has been associated with concerns regarding professional autonomy, patient-centeredness, and organizational ethics. This study examines how physicians and hospital managerial stakeholders perceive the DRG system, focusing on professional identity, patient care, and moral conflict. Methods: We conducted a cross-sectional online survey among hospital physicians and managerial stakeholders in two German federal states (North Rhine–Westphalia and Saxony-Anhalt). The questionnaire assessed perceived economic pressure, ethical conflict, and quality-of-care implications under DRG conditions. Descriptive comparisons and multivariable logistic regression were used to estimate associations between professional role and reported ethical concerns. Results: Physicians more frequently reported perceived moral conflict (82% vs. 34%), reduced patient-centeredness (76% vs. 39%), and time pressure associated with DRG-linked hospital financing (85% vs. 71%) than managerial respondents. Managerial stakeholders more frequently emphasized efficiency and coordination gains. Both groups supported the use of quality indicators to protect care standards, though physicians were more likely to call for rebalancing financial and clinical priorities. Conclusions: Physicians and managerial stakeholders perceive DRG-linked incentives differently, and both groups identify ethical pressure points in current hospital financing. The findings suggest that hospital financing reforms should consider not only efficiency incentives but also their perceived interaction with professional ethics, continuity of care, and organizational culture.