Hybrid diagnosis-related groups-The challenge

Abstract

The introduction of hybrid diagnosis-related groups (DRG) presents new challenges for healthcare providers and health insurances. The same applied in 2023 to the institute designated by the Federal Ministry of Health (BMG) to extract medical procedures and calculate remuneration levels for the first hybrid DRGs. Aresponsible calculation methodology and arealistic data basis are required as the result of the calculation can lead to controversy, even to a splitting among specialist groups and constructs. There is also the threat of mismanagement with subsequent supply problems. In this context, aloss of quality can occur due to the use of simple surgical procedures that are less complex and not expensive with respect to material costs and are economical but not state of the art and thus directly worsen the medical care of patients in the statutory health insurance (GKV). Furthermore, it is already becoming apparent that procedures that are uneconomical due to the miscalculation are partially no longer being comprehensively rendered by healthcare providers due to adjustment of the service portfolio. An appropriate compensation of procedures is only possible based on a remuneration that adequately covers the costs. In this respect, this article is not intended to be understood as a"solution to the problem of the internal distribution of the remuneration in hybrid DRGs" but more to offer suggestions for solutions for the required further development of the hybrid DRG compensation level calculation to prevent a threat to the treatment of GKV patients due to mismanagement. As required in §115fof the SozialgesetzbuchV (SGBV), the recalculation of an economic remuneration must be carried out urgently and promptly using an empirical calculation basis and methodology and this must be regularly adapted.