German Diagnosis-related Group System Research Articles

The Megaendoprosthesis in Revision Arthroplasty - a Cost-revenue Analysis in the aG-DRG System.

Megaendoprosthesis offer a viable treatment in complex revision arthroplasty cases with good functional outcome. In the context of a neoplastic indication, the diagnosis-related group (DRG) I95A is usually assigned with a relative weight of 4.906 (2021). In contrast, in revision arthroplasty, the appropriate DRG is assigned, depending on the joint replacement. The additional costs compared to the invoiced DRG are to be compensated by agreeing on hospital-specific individual fees. These complex revision arthroplasties set high technical and operative demands and are mainly performed in specialised departments. We conducted a cost-benefit analysis of the use of the megaendoprosthesis in revision cases in a specialised orthopaedic clinic, as a single centre study. The question we sought to answer was: Is cost recovery possible in the modified German DRG system (aG-DRG)?A retrospective single centre analysis of treatment costs was performed. From 2018 to 2020, 113 patients treated with a megaendoprosthesis reconstruction in a referral centre due to extensive bone loss after aseptic or septic revision of a hip or knee prosthesis were included in the study. Relevant case-related cost drivers of the aG-DRG matrix (including staff and material costs of the operating theatre area and the ward) were taken into account. The actual costs were determined according to the specifications of the calculation manual published by the German institute for the remuneration system in hospitals (InEK). For each case, the contribution margin was calculated by relating the hospital's internal costs to the corresponding cost pool of the aG-DRG matrix.According to the DRG system 2021, 17 different DRGs were used for billing - in 70% based on a patient clinical complexity level (PCCL) ≥4. Compared with the InEK calculation, there is a deficit of -2,901€ per case in the examined parameters. The costs of physicians show a shortfall in both the operating theatre and on the ward. Implant costs, which were supposed to be compensated by hospital-specific additional charges, show a hospital-specific shortage of -2,181€. When analysing the risk factors for cost recovery, only these showed a significant difference.Implantation of the megaendoprosthesis in revision arthroplasty is often the last option to preserve limb function. At present, despite a high degree of specialisation and process optimisation, this treatment cannot be provided cost-effectively even in tertiary care. The politically desired specialised department structure requires sufficient reimbursement for complex cases. The economic outcome of each treatment case is often unpredictable, however the surgeon is confronted with these cases and is expected to treat them. The high standard deviation indicates large differences in the cost/revenue situation of each individual case. Our results show for the first time a realistic cost analysis for megaprosthesis in revision arthroplasty and underline the importance of an adequate hospital-specific charge, individually agreed by the funding units. The calculation should include not only the implant costs, but also the increased staff costs (increased, complex planning effort, quality management, surgery time, etc.).

Cost-utility analysis of early versus delayed endovascular intervention in critical limb-threatening ischemia patients with rest pain.

The prevalence of chronic limb-threatening ischemia (CLTI) and poor health outcomes are high in Germany. Serious consequences of CLTI such as amputation and mortality can be effectively prevented by the early use of evidence-based therapeutic measures such as endovascular intervention. We have developed a cost-utility analysis to compare endovascular intervention with bare metal stents (BMSs) and endovascular intervention after conservative treatment from the German payer perspective. A Markov model, with a 5-year time horizon and seven states, was developed: (1) intervention, (2) stable1, (3) major amputation, (4) reintervention, (5) stable2, (6) care, and (7) all-cause death. Transition probabilities were obtained by pooling the outcomes from multiple clinical studies. The costs were estimated using data from the German diagnosis-related group system, the German rehabilitation fund, and related literature. Health-state utilities were obtained from the reported data. The primary outcomes were the quality-adjusted life-years (QALYs) and costs. Early BMS intervention after 5years resulted in a cost of €23,913 and an increase of 2.5 QALYs per patient, and endovascular intervention with BMS after conservative treatment after 5years resulted in a cost of €18,323 and an increase of 2 QALYs per patient. The incremental cost-effectiveness ratio was €12,438. The number of major amputations was reduced by 6%. The results of the structural, deterministic, and probabilistic sensitivity analyses were robust. Early endovascular intervention with BMS resulted in more QALYs and a reduced risk of major amputation for early-stage CLTI patients. Our results showed that early endovascular intervention is very cost-effective according to World Health Organization recommended cost-effectiveness thresholds. However, the clinical decision regarding the use of early endovascular intervention should be determined by individual patient-level eligibility and the physician's judgment.

Principal-agent theory-based cost and reimbursement structures of isavuconazole treatment in German hospitals.

Isavuconazole (ISA) is a frequently used antifungal agent for the treatment of invasive fungal diseases (IFDs). However, hospital reimbursement data for ISA is limited. The primary objective of this study was to analyse the different perspectives of relevant stakeholders and the (dis)incentives for the administration of ISA in Germany. To that aim, the health economic effects of using ISA from a hospital management perspective were analysed. Based on principal-agent theory (PAT), the perspectives of (a) the patient (principal) as well as (b) physicians, (c) pharmacists and iv. hospital managers (all agents) were analysed. For the evaluation of the cost-containment and reimbursement strategies of ISA, the German diagnosis-related group (G-DRG) system was used. Hospitals individually negotiating additional payments for innovative treatment procedures (zusatzentgelte [ZE]) within the G-DRG system is a key element of hospital management for the reduction of total healthcare expenditure. Our analysis demonstrated the beneficial role of ISA in healthcare resource utilisation, primarily due to a shortened overall length of hospital stay. Depending on underlying disease, coded G-DRG and ISA formulation, large differences in total reimbursement and the amount of ZE was shown. The PAT demonstrated disincentives for hospital managers to use innovative drugs. Based on the PAT, beneficial, detrimental and indifferent perspectives of different stakeholders regarding the usage of ISA were shown. A reduction of bureaucratic hurdles is needed in Germany for the extension of effective and innovative antifungal treatment strategies with ISA.

Influence of a spontaneous bacterial peritonitis, nosocomial infections and acute-on-chronic liver failure on treatment revenues in patients with decompensated cirrhosis in Germany

The economic effects of spontaneous bacterial peritonitis (SBP), nosocomial infections (nosInf) and acute-on-chronic liver failure (ACLF) have so far been poorly studied. We analyzed the impact of these complications on treatment revenues in hospitalized patients with decompensated cirrhosis. 371 consecutive patients with decompensated liver cirrhosis, who received a paracentesis between 2012 and 2016, were included retrospectively. DRG (diagnosis-related group), "ZE/NUB" (additional charges/new examination/treatment methods), medication costs, length of hospital stay as well as different kinds of specific treatments (e. g., dialysis) were considered. Exclusion criteria included any kind of malignancy, a history of organ transplantation and/or missing accounting data. Total treatment costs (DRG + ZE/NUB) were higher in those with nosInf (€ 10,653 vs. € 5,611, p < 0.0001) driven by a longer hospital stay (23 d vs. 12 d, p < 0.0001). Of note, revenues per day were not different (€ 473 vs. € 488, p = 0.98) despite a far more complicated treatment with a more frequent need for dialysis (p < 0.0001) and high-complex care (p = 0.0002). Similarly, SBP was associated with higher total revenues (€ 10,307 vs. € 6,659, p < 0.0001). However, the far higher effort for the care of SBP patients resulted in lower daily revenues compared to patients without SBP (€ 443 vs. € 499, p = 0.18). ACLF increased treatment revenues to € 10,593 vs. €6,369 without ACLF (p < 0.0001). While treatment of ACLF was more complicated, revenue per day was not different to no-ACLF patients (€ 483 vs. € 480, p = 0.29). SBP, nosInf and/or ACLF lead to a significant increase in the effort, revenue and duration in the treatment of patients with cirrhosis. The lower daily revenue, despite a much more complex therapy, might indicate that these complications are not yet sufficiently considered in the German DRG system.

Accounting for What Matters to Patients in the G-DRG System: A Stakeholder's Perspective on Integrating Functioning Information.

Functioning information constitutes a relevant component for determining patients’ service needs and respective resource use. Diagnosis-Related Group (DRG) systems can be optimized by integrating functioning information. First steps toward accounting for functioning information in the German DRG (G-DRG) system have been made; yet, there is no systematic integration of functioning information. The G-DRG system is part of the health system; it is embedded in and as such dependent on various stakeholders and vested interests. This study explores the stakeholder’s perspective on integrating functioning information in the G-DRG system. A qualitative interview study was conducted with national stakeholders in 4 groups of the G-DRG system (health policy, administration, development, and consultations). Interviews were analyzed using inductive thematic analysis. In total, 14 interviews were conducted (4 administration and 10 consultation group). Three main themes were identified: (1) functioning information in the G-DRG system: opportunities and obstacles, (2) general aspects concerning optimizing G-DRG systems by integrating additional information, and (3) ideas and requirements on how to proceed. The study offers insights into the opportunities and obstacles of integrating functioning information in the G-DRG system. The relevance of functioning information was evident. However, the value of functioning information for the G-DRG system was seen critically. Integrating functioning information alone does not seem to be sufficient and a systems approach is needed.

„Etwas Menschliches ist verloren gegangen“. Erfahrungen leitender Ärzte in Bezug auf das DRG-System – eine qualitativ-normative Analyse

Only a few years after the implementation of the G-DRG (German Diagnosis Related Group) system physicians already began to complain of its negative effects on the quality of inpatient healthcare. The present study examines the recent experiences senior physicians have made with regard to the impact of the G-DRG system on the quality of healthcare and medical professionalism. Nine qualitative guided expert interviews were conducted focusing on the experiences of physicians in leading positions dealing with the G-DRG system in their everyday work. The interviewees report an intensification of work attributable to an increasing number of inpatient cases, a more lenient definition of medical indications and a reduction in patient retention time. The physicians interviewed have felt increasingly constrained by economic conditions. Additionally, they stated that the G-DRG system's incentive structure encourages the discrimination of older, care-dependent and multimorbid patients. Possible countermeasures include a political revision of incentive regulation as well as a strengthening of up-to-date professional ethical education and teaching.

Reimbursement for Hospital-acquired Infections with Multidrug Resistant Organisms in German DRG System

IntroductionHospital-acquired infections (HAIs) are of immense clinical, epidemiological and ethical importance for healthcare systems worldwide (ECDC, 2012; Jarvis, 1996). Many of these infections are caused by multidrug resistant organisms (MDROs), of which the Methicillin Staphylococcus aureus (MRSA) is the most common one. High economic burden of HAIs can be referred to increased co-morbidity and mortality resulting in prolonged hospital lengths of stay as the main cost driver (Cosgrove et al., 2005; de Kraker et al., 2011; Wenzel, 1995; Zimlichman et al., 2013). Multidrug resistant pathogens complicate treatment procedures considerably and lead to significantly longer hospital lengths of stay (de Kraker et al., 2011). In 2008, the European Centre for Disease Prevention and Control (ECDC) estimated 171,200 nosocomial MRSA infections, 5,400 attributable excess deaths and more than 1 million excess days of hospitalization per year which goes along with 380 million Euros excess in-hospital costs per year (ECDC, 2012).To combat the spread of multiresistant bacteria, hospitals are confronted with additional costs due to hygienic measures, e.g. admission screening, and precaution isolation of patients (Herr et al., 2003; Hubner et al., 2014; Wilcox, 2004). A few studies demonstrate a positive cost-benefit ratio of theses hygiene preventive measures (Farbman et al., 2013). Nevertheless, these additional costs are only partly accounted in hospital financing systems (Vegni et al., 2004). The financial impact of nosocomial infections on reimbursements under prospective Diagnosis Related Group (DRG) conditions is already long controversially debated (DeWitt, 1987). MDROs present a new challenge not least because of their growing clinical importance. However, there are hardly any scientific studies conducting the impact of MDRO-infections on the DRG-system.1. Encoding of multiresistant organism in the German DRG-systemThe German DRG System was introduced in 2003 and contains a diagnosed-regarded, lump-sum classification system. Each DRG corresponds with an economically-comparable case-group specified by the clinical diagnosis, diagnostic and therapeutic interventions as well as patients' comorbidities and subsequent complications. Key elements of a DRG are the mean length of stay with a lower and an upper limit, which indicates discount or surcharge rates, and the cost weight. There are ICD-10-based secondary diagnoses for the coding of comorbidities as well as OPS-codes for special performed procedures.Over the past years several adjustments of the DRG system have been made, whereby also hospital acquired infections with multidrug-resistant pathogens should be better reflected. Originally, these costs were not included in DRGs and therefore not covered (Vegni et al., 2004). A positive MDRO-status can be indicated by the secondary diagnosis U80.0! or U81.0! in combination with Z22.3 Z29.0. (colonization) or B.95.6 (infection). For the isolation of MDRO-positive patients, the OPS 8-987! should be used if minimum requirements are met (documented additional expenses of at least 2 hours per day, e.g. for special experienced staff, screening, isolation and decolonization measures, over at least 7 days). Since 2007 specific complex DRG for MDRO-associated diseases exist for encoding.The encoding of MDOR-relevant parameters may have an impact on the hospital revenue, as the following example shows (Table 1).The example of Table 1 shows a difference of 575.09 Euro in favour of encoding of MDRO-parameters. This revenue growth is relatively low compared to the additional cost due to hygienic prevention measures and other therapeutic procedures (Herr et al., 2003; Hubner et al., 2014). Furthermore, encoding of MDRO-parameters does not always result in a revenue relevance, sometime it can be even revenue reductive (de Zeeuw and Baberg, 2009). If the required conditions for OPS 8-987! can not be achieved, no MDRO-relevant encoding is possible at all. …

Procalcitonin: a valuable markerfor assessment of the success of antimicrobial therapy for severe sepsis An analysis using routine clinical data

Introduction and Objectives Procalcitonin (PCT), a precursor of the hormone calcitonin, is produced byC cells inthe thyroid. PCT is consistently produced duringsevere bacterial infections,causing its levels to increase [1,2].However,increased PCT levels are alsocharacteristic of other disease states, such as calcitonin-producing tumors, medullary C-cell carcinoma of the thyroid, acute respiratory distress syndrome,and invasive fungal infections. In particular,extensive clinical evidence indicates that PCT is a biomarker for both follow-up and evaluation ofthe effectiveness of antibiotic therapyfor severe respiratory infections and sepsis; in all relevant guidelines, the use of PCT in this contextis categorized asevidence class 2B or 2C [3,4]. For example, PCT levels differentiatemore effectivelybetween sepsis and systemic inflammatory response syndrome (SIRS)than those ofIL-6, IL-8, or CRP[5,6]. A meta-analysis of several clinical studiesofvarious infections demonstrated that PCT-guided antibiotic therapyreduced both therapy duration and the length of stay in intensive care [7].Based on this broad evidence, another meta-analysis focused on sepsiswas conducted, the results of whichindicatedthat antibiotic therapy can be curtailed by a mean of four days, and length of ICU stay reduced by a meanof 1.8 days. Based on existing algorithms,we determinedasequence of PCT measurementsappropriateto guide the use ofantibiotic therapy. In addition,rules for when therapy should commence and end, and cut off values to evaluate successful treatment have been established. Implementation of this system may introduce savings for the German diagnosis-related group(G-DRG) system [8]. A fall in PCT levelsby 80% compared withthe highest value, or to 0.25 ng/ml, indicatesuccessful antibiotic therapy. Hochreiter and Schroder showed that,in the case of adequate antibiotic therapy,PCT levels decreasesignificantly after 4 days [9]. In addition, Charles et al. demonstrated that a lack of PCT reduction on day 3,compared withday 2, of antibiotic therapyis a resilient indicator of inadequate treatment (OR = 10.29) [10]. Once guidelines and algorithms have been established for some time, the question of how well they are implemented in practice in theclinic arises.

Effects of malnutrition on complication rates, length of hospital stay, and revenue in elective surgical patients in the G-DRG-system

ObjectiveMalnutrition is known to independently affect patient outcomes. The aim of this study was to investigate the prevalence of patients at risk for malnutrition in an elective surgery patient cohort and to analyze the effects of malnutrition on morbidity, mortality, and hospital length of hospital (LOS). Furthermore, we aimed to evaluate the economic effect of a diligent coding of malnutrition, as a side diagnosis, in a simulation of the German Diagnosis-Related Group system. MethodsThe nutritional status of 1244 patients undergoing elective surgery was standardized on the day of admission by the Nutritional Risk Screening (NRS) 2002. To quantify the influence of malnutrition on revenue, the real DRGs of all patients were grouped. In simulation, an appropriate International Classification of Diseases code was used as a secondary diagnosis for all malnourished patients based on the NRS rating. A multivariate logistic regression analysis and a Cox regression were performed to identify potential confounders and to determine the adjusted effect of nutritional status on the occurrence of complications and hospital LOS. ResultsThe prevalence of patients at risk for malnutrition (NRS ≥3) was 24.1% (300 of 1244). These patients showed a significant increase in hospital LOS (13 versus 7 d). Additionally, postoperative complications were significantly higher in this group (7.23% versus 6.91%). Including malnutrition in the Diagnosis-Related Group coding system resulted in a reimbursement of €1979.67 per patient at risk for malnutrition and a total reimbursement of €79,186.73 for all patients at risk for malnutrition in the present study. ConclusionEstablishment of a structured, comprehensive assessment of the nutritional status of hospitalized patients can repetitiously identify patients at risk for malnutrition. Additionally, the diligent codification of malnutrition can lead to cost compensation in the German Diagnosis-Related Group system.

Positionspapier des Verbandes pneumologischer Kliniken und der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin zur Kodierung der invasiven und nicht-invasiven Beatmung bei intensivmedizinisch versorgten Patienten

Mechanical ventilation in patients with respiratory failure represents one of the most important aspects of intensity care. It can be performed invasively and non-invasively depending on the clinical situation and the underlying disease. The expenditure and consumption of resources is the basis of the compensation for each patient case in the German diagnosis related group system. For ventilated patients it is calculated based on the hours of ventilation, according to the standard coding guideline. In this statement, the German Respiratory Society and the Association of Pneumological Clinics aim to clarify some aspects of the coding of invasive and non-invasive ventilation.

A multi-perspective cost-effectiveness analysis comparing rivaroxaban with enoxaparin sodium for thromboprophylaxis after total hip and knee replacement in the German healthcare setting.

BackgroundPatients undergoing major orthopaedic surgery (MOS), such as total hip (THR) or total knee replacement (TKR), are at high risk of developing venous thromboembolism (VTE). For thromboembolism prophylaxis, the oral anticoagulant rivaroxaban has recently been included in the German diagnosis related group (DRG) system. However, the cost-effectiveness of rivaroxaban is still unclear from both the German statutory health insurance (SHI) and the German hospital perspective.ObjectivesTo assess the cost-effectiveness of rivaroxaban from the German statutory health insurance (SHI) perspective and to analyse financial incentives from the German hospital perspective.MethodsBased on data from the RECORD trials and German cost data, a decision tree was built. The model was run for two settings (THR and TKR) and two perspectives (SHI and hospital) per setting.ResultsProphylaxis with rivaroxaban reduces VTE events (0.02 events per person treated after TKR; 0.007 after THR) compared with enoxaparin. From the SHI perspective, prophylaxis with rivaroxaban after TKR is cost saving (€27.3 saving per patient treated). However, the cost-effectiveness after THR (€17.8 cost per person) remains unclear because of stochastic uncertainty. From the hospital perspective, for given DRGs, the hospital profit will decrease through the use of rivaroxaban by €20.6 (TKR) and €31.8 (THR) per case respectively.ConclusionsBased on our findings, including rivaroxaban for reimbursement in the German DRG system seems reasonable. Yet, adequate incentives for German hospitals to use rivaroxaban are still lacking.

Kosten- und Leistungsheterogenität bei penetrierenden Augenverletzungen und Amnionmembranaufnähungen unter DRG-Bedingungen

Patients with penetrating eye injuries are a very heterogeneous group both medically and economically. Since 2009, treatment involving sutures for open eye injuries and cases requiring amniotic membrane transplantation (AMT) were allocated to DRG C01B of the German diagnosis-related group system. However, given the significant clinical differences between these treatments, an inhomogeneity of costs to performance is postulated. This analysis describes case allocation problems within the G-DRG C01B category and presents solutions.A retrospective analysis was conducted from the standardized G-DRG data of 277 patients with open eye injuries and AMT between 2007 and 2008, grouped under the 2008 G-DRG system version to the G-DRG C01Z category. This data was provided by the Department of Ophthalmology at the University Hospital Regensburg. Additionally case-based data of the following were supplemented: length of surgery, time of anesthesia and intensity of patient care. Fixed and variable costs were determined for surgery and other inpatient treatment. Finally, an analysis of the heterogeneity of costs within the G-DRG C01B of the G-DRG system 2009 was implemented.Inhomogeneity was evident within the G-DRG C01B of the G-DRG system 2009 for the two groups suture of open eye injuries and AMT concerning the parameters length of stay, proportion of high outliers and cost per case. Multiple surgeries during an inpatient stay lead to an extended length of stay and increasing costs, especially within the AMT group. Intensity of patient care and the consideration of patient comorbidity did not yield relevant differences.The quality of the G-DRG system is measured by its ability to obtain adequate funding for highly complex and heterogeneous cases. Specific modifications of the G-DRG structures could increase the appropriateness of case allocation for patients with open eye injuries within the G-DRG C01B of the German DRG system 2009. As a result of the present study, cases with amniotic membrane transplantation should not be allocated to the G-DRG C01B. A petition has been presented by the German Association of Ophthalmology (DOG) to the German DRG Institute to restructure the G-DRG C01B. Data-based analysis is an essential prerequisite for a constructive development of the G-DRG system and a necessary tool for the active participation of medical societies in this process.

Diagnosis-Related Groups als Steuerungssystem zur Entwicklung leistungsgerechter Fallpauschalen in der Hämatologie und Onkologie

Im Jahr 2003 wurde für deutsche Krankenhäuser ein neues Abrechnungssystem eingeführt, das auf Basis von einigen hundert Fallpauschalen sämtliche etwa 17 Millionen stationären Fälle pro Jahr nach einem leistungsorientierten, pauschalierten und international erprobten System abbilden sollte. Ziel war es, die stationären Fälle hinsichtlich Kosten und Erlösen gerechter abzubilden. Das deutsche Diagnosis-Related Groups (DRG)-System konnte in den ersten beiden Jahren nach Einführung die komplexen Abläufe der stationären Hämatologie und Onkologie noch nicht adäquat abbilden. Durch den Ausbau der Diagnosen- und Prozedurenkataloge (Internationale Klassifikation der Krankheiten 10 (ICD-10) und Operationen- und Prozedurenschlüssel (OPS)), die Schaffung neuer sowie die bessere Unterteilung bestehender Fallpauschalen konnte das Fachgebiet deutlich besser dargestellt werden. Weiterhin wesentlich waren die Schaffung von etwa 70 Zusatzentgelten für die Vergütung neuer und teurer Medikamente und Verfahren sowie das Verfahren zur überbrückenden Vergütung von Innovationen bis zur Abbildung im DRG-System (Neue Untersuchungs- und Behandlungsmethoden, sogenanntes NUB-Verfahren). Damit ist die Hämatologie und Onkologie im stationären Bereich bis in Extremkostenfälle gut abgebildet. Rationierungstendenzen konnten in der stationären Behandlung bisher verhindert werden, da sämtliche erforderlichen Maßnahmen und Medikamente im Wesentlichen kostendeckend abgebildet sind.

Effect of the introduction of diagnosis related group systems on the distribution of admission weights in very low birthweight infants

BackgroundAdmission weight to neonatal intensive care units is used in several diagnosis related group (DRG) systems to assess reimbursement by health insurance programs for premature infants. Modifications of admission weights...

Coronary Stents and the Uptake of New Medical Devices in the German System of Inpatient Reimbursement

This study aims to analyze mechanisms for facilitating the uptake of new medical devices in the German system of hospital reimbursement, focusing on the example of coronary stents, including (1) trends in their coding, (2) associated diagnosis-related group (DRG) payments, (3) their integration in the German DRG (G-DRG) system, and (4) their diffusion within the inpatient sector. Published and gray literature provide the basis for analyzing the system of hospital reimbursement. Data on coronary stents were obtained from various regulatory and government bodies and examined in a longitudinal fashion. Although German Procedure Classification (Operationen- und Prozedurenschlüssel; OPS) codes were created for a range of stent technologies between 2004 and 2009, the regular system of G-DRG reimbursement does not distinguish between different stents by means of unique DRGs. Instead, supplementary payments or extrabudgetary payments are used to ensure that newer technologies are reimbursed adequately. The limitations of extrabudgetary payments restrict the use of some devices to a small proportion of patients. Data on the diffusion of different stents show that factors other than the reimbursement regime likely also play a role in the frequency with which certain technologies are used. Bare metal stents currently account for most stent implantation procedures in Germany, followed by drug-eluting stents. The current system of G-DRG reimbursement and of extrabudgetary payments ensures that even the most recently developed technologies can be used in the German inpatient sector. Nevertheless, certain technologies may not be reaching the broad patient population.

Extrabudgetary ('NUB') payments: A gateway for introducing new medical devices into the German inpatient reimbursement system?

Abstract Most new medical devices in Germany are first introduced in the inpatient sector. The key hurdles to marketing them are thus to ensure their inclusion in the German Diagnosis-Related Group (G-DRG) system and to bridge the financial gap in the interim. In 2005, a system of extrabudgetary payments was introduced to bridge this gap and to expedite the inclusion of new technologies in the G-DRG system. The present study aims (1) to describe prototypical regulatory pathways for including new medical devices and other technologies in the G-DRG system and (2) to analyse real-world data on applications for extrabudgetary reimbursement to determine the pathways these technologies followed between 2005 and 2009. The findings show that the technologies did indeed follow the prototypical pathways and that patients' access to them has been improved by the system of extrabudgetary payments. Some technologies, however, have still not been fully included in the G-DRG system, even after four years. Moreover, impr...

Minimally Invasive, Minimally Reimbursed? Anesthesia for Endoscopic Cardiac Surgery Is Not Reflected Adequately in the German Diagnosis-Related Group System

Minimally Invasive, Minimally Reimbursed? Anesthesia for Endoscopic Cardiac Surgery Is Not Reflected Adequately in the German Diagnosis-Related Group System

Costs of dialysis--a regional population-based analysis

Population-based estimates of costs of renal replacement therapy are scarce in the literature. The aim of our study was to calculate the costs of long-term dialysis in 2006 on the basis of patient-specific data from a well-defined population in a region in western Germany (n = 310,757). Cost estimation was performed from the perspective of the statutory health insurance. All dialysis patients from the study region (n = 344, 54% male, mean age (+/-SD) 69 +/- 13 years, 42% diabetic) were assessed for the costs of the dialysis procedures, dialysis-related hospital admissions, outpatient contacts outside of our dialysis center, dialysis-related medication, patient transportation and related costs (e.g. reimbursement fees on the basis of the German diagnosis-related group system, price scales). We estimated the cumulative cost per patient year in 2006 (in Euros), along with the 10th and 90th percentiles and the 95% confidence intervals (CI) by using bootstrapping procedures. The mean total dialysis-related cost in 2006 was 54,777 Euros (95% CI, 51,445-65,705) per patient year. The largest part of the costs (55%) was caused by the dialysis procedures, followed by the costs of medication (22%), hospitalization (14%) and transportation (8%). The total cost increased significantly with increasing age. No significant association was found between total cost and sex, dialysis strategy, end-stage renal disease duration and diabetes. We present for the first time a cost estimation of dialysis in Germany on the basis of patient-level data in a population-based sample. Except age, patient characteristics were not significantly associated with costs. The largest part of the costs was caused by the dialysis procedures themselves; however, other dialysis-specific health care utilization also strongly contributed to the total cost.

Minimally Invasive, Minimally Reimbursed? Anesthesia for Endoscopic Cardiac Surgery Is Not Reflected Adequately in the German Diagnosis-Related Group System

In the German diagnosis-related group (G-DRG) system, hospital reimbursement for anesthesia is linked to specific surgical procedures, irrespective of case duration. Accordingly, costs of innovative procedures, such as endoscopic cardiac surgery, may be underreimbursed. The authors assessed to what extent anesthesia costs for endoscopic cardiac surgery are reimbursed with the G-DRG system. Retrospective analysis. University hospital. Eighty-four patients were studied undergoing general anesthesia for minimally invasive endoscopic port-access intracardiac surgery (n = 42) or conventional "open" surgery (n = 42) for similar indications. None. The authors measured anesthesia staffing time, costs, and reimbursement for endoscopic cardiac surgery and compared results with data from a matched group undergoing conventional surgery. Endoscopic surgery increased anesthesia staffing time per case by 521 minutes (977 minutes +/- 177 v 456 +/- 92, mean +/- standard deviation, p = 0.0001) and costs by approximately 200%. Anesthesia duration increased by 152 minutes (503 minutes +/- 89 v 351 +/- 69, p = 0.0001). In contrast, staffing reimbursement did not increase at the time of the patient's surgery (euro500/case [446-569] v 492 [452-508], p = 0.75, median [interquartile range]) or with the 2007 G-DRG matrix (euro548/case [463-559] v 503 [503-568], p = 0.48). Cost recovery was only 66% +/- 17.4% and 72.7 +/- 38.9 in the 2007 G-DRG matrix, respectively. It was shown that (1) endoscopic cardiac surgery consumed more anesthesia resources and was underreimbursed both relative to actual costs and to conventional surgery, (2) costs for such anesthesia services were inappropriately reflected in the G-DRG system, and (3) a DRG system's inability to adapt timely to innovative procedures may adversely affect anesthesia departments and medical progress.

DRG-Prüfergebnisse im Ländervergleich: MDK Baden-Württemberg und MDK Westfalen-Lippe

We report on the first detailed comparison of evaluation results regarding the correct billing in the G-DRG (German diagnosis-related group) system. For two Medical Review Boards of the Statutory Health Insurance Funds of comparable size (MDK Baden-Württemberg and MDK Westfalen-Lippe), we analysed consecutive expertises regarding correct billing according to section sign 275 SGB V, and the results were compared in terms of the frequency of DRG-relevant error codes, their relevance to revenue, and the question of error clustering (specific DRGs, primary diagnoses, etc.). The analysis comprised 51,010 individual expertises pertaining to billings of the year 2005 (admittance to hospital from January 1 to December 31, 2005). The proportion of disapproved cases was 38.5% in Baden-Württemberg and 44.6% in Westfalen-Lippe. Among these, errors to the disadvantage of the Health Insurance (incorrectly high) were 33.9% and 39.3%, respectively, and errors to the disadvantage of the hospitals (incorrectly low) were 4.6% and 5.3%, respectively. The resulting ratio (incorrectly high vs. low) was an identical 7.4 in both cases. Not only the most commonly rejected DRGs but also the primary and secondary diagnoses were similar in both cases, while the disapproved procedure codes showed a significant variability (analysis based on the respective 10 most common objections). We discuss the similarities and differences in these results and their possible causes, and demonstrate the cost relevance of this audit segment. Result comparisons of this type can yield insights into streamlining of the review practice of Medical Review Boards, as well as increase the efficiency and effectiveness of the selection of cases.