German DRG System Research Articles

Reimbursement of New Health Technologies in a DRG-System

Rationale: A prospective reimbursement system based on Diagnosis Related Groups (DRGs) has been recently introduced in several European countries for acute inpatient treatment, e.g. in Germany in 2003. To enable the application of new health technologies a special reimbursement process has been developed for those technologies. Objectives: To present how new technologies can be reimbursed under DRG-conditions, using Germany as a case example. Methods: Material of the official German DRG-Institute (InEK - Institut fur das Entgeltsystem im Krankenhaus gGmbH), the German hospital society (DKG - Deutsche Krankenhausgesellschaft) and the biggest German health insurance (AOK - Allgemeine Ortskrankenkasse) was screened manually and electronically. In addition, interviews with experts of those organisations were conducted. Results: New technologies causing higher costs for hospitals are not adequately compensated within the current G- (German) DRG-system. Since 2005, they can be reimbursed with a special add on (NUB - Neue Untersuchungs- und Behandlungsmethode). Each hospital has to apply for a NUB individually by the end of October at the InEK which decides by the end of December whether the respective hospital will get a NUB for one year. This decision is based on the submitted evidence on the medical effectiveness and economic impact of the new technology on the hospital. The NUB will not be granted if there is not enough medical or economic evidence or if the new technology does not lead to a specific increase of costs. The value of this threshold is only known by the InEK. The amount of the NUB depends on negotiations between the individual hospital and the sick funds and can differ between hospitals. When there is enough data of resource use and costs for the new technology the InEK will determine either (1) a national add on (Zusatzentgelt) which is applicable for all hospitals or (2) adjust the payments for the existing DRGs which include the new technology or (3) even create a new DRG. The number of NUBs substantially increased from 26 in 2005 to 54 in 2006 while the number of national add ons increased from 71 to 82 in the same time period indicating that the system enables the dissemination of technologies causing higher costs for the hospital. Conclusions: The G-DRG-system seems not to substantially hinder the introduction and adaptation of new technologies causing substantially higher costs for the hospital. However, there are no incentives to implement new technologies that are rather inexpensive for the hospital. Clearly, this problem should be addressed by the InEK.

Hüftgelenks-Endoprothetik im DRG-System

Due to the continuing increase in life expectancy, the ageing process of the German population in general and the high demands placed on activity levels and quality of life today, the demand for primary and secondary joint replacement surgery continues to increase. To distribute the economic and medical resources properly, while still making technical and surgical innovations available to a broad public, hospitals must be able to adequately finance these procedures with the help of the proper diagnosis related groups. The development of the German DRG-system over the past years, as well as the new calculation for the year 2006 are to be reviewed and analysed in this article with this in mind. An improvement in the degree of differentiation between the individual procedures can be documented. Whether or not these changes will ensure the long-term financial survival of the German health care system will remain to be seen.

DRGs und Pflegesätze in der Psychosomatik: 2002-2005

Over the last years the use of diagnosis-related groups (G-DRG) was introduced into most areas of the German health care system, which led to changed compensation for departments outside the G-DRG system as well. We evaluated the development of revenues in 17 different psychosomatic departments over the last three years. Our analyses were based on official daily rates for each of the clinics included. If daily rates changed within one year, we used the average daily rate for that year. Together all departments provided 547 in-patient beds for the treatment of acute psychosomatic patients. With 85% occupancy all departments would achieve a revenue of 62.5 million euro in 2005, two million euro less than three years previously. Due to the introduction of the German DRG system their average income was reduced by approx. 3%. The loss was greater for psychosomatic departments at larger hospitals, which have a higher percentage of departments included in the G-DRG system. The introduction of the G-DRG system leads to reduced revenues for departments outside the G-DRG system, while performance was expected to remain at the same level and costs have increased. Thus, to ensure the spectrum of psychosomatic medicine as it is today, it has become increasingly important to demonstrate the real costs of treatment to political decision makers.

Cost accounting to determine prices: How well do prices reflect costs in the German DRG-system?

Germany has recently introduced a system of Diagnosis Related Groups (DRGs) to engender more appropriate resource allocation. The following article describes the German DRG-system and the methodologies used to determine prices. It analyses the extent to which prices, or calculated cost weights, reflect the actual costs incurred by hospitals for their respective services. We reveal that a "compression" of DRG cost weights occurs, and that the data sample used to calculate cost weights is lacking in terms of its representativeness. Although cost data accuracy has improved over the last few years there are still a number of challenges that need to be addressed.

Implementierung der multizentrischen Basisdokumentation CL-BaDo für den Konsiliarund Liaisondienst: Generierung von Daten für internes Qualitätsmanagement und Kostenkalkulation/ Implementation of the multi-center basis documentation CL-BaDo for conciliar and liaison services: Generating data for internal quality management and cost calculation

In the German DRG system the funding of CL services is not ensured. The documentation of psychiatric comorbidity and CL care delivery is a pre-condition to the development of funding models for CL-services. A task force of several German psychosomatic associations (German College of Psychosomatic Medicine, German Society of Psychosomatic Medicine and Psychotherapy, General Medical Society for Psychotherapy) developed a new documentation form for CL-services (CL-BaDo). The pilot study explored the multicenter implementation of CL-BaDo and the use of the documentation form for quality management and cost calculation. Over a period of at least three months, participating CL-services documented all CL cases consecutively with the CL-BaDo. One site applied full electronic data processing. 2116 CL cases from eight psychosomatic CL-services were analysed. The CL-BaDo is a time-efficient, feasible and acceptable documentation form for CL-service delivery. The full electronic data processing enables networking with a hospital information system to produce higher data quality. The data of CL-BaDo can be used locally for quality management, development of management strategies and communication with consultants, as well as nationwide for health policy questions and research.

Wechseloperationen in der Kniegelenkendoprothetik im DRG-System

Due to an increasing life expectancy and earlier primary implantation of total knee replacements, the number of patients requiring revision surgery in Germany is increasing by 7% every year. These revision cases belong to the most treatment and cost intensive operations in joint replacement surgery. Presently, the description of these procedures in the German DRG system, which defines the financial reimbursement for the hospitals, is changing yearly with the development of new catalogues. The changes made from 2003 to 2005 are outlined in the following article. A correct depiction of the treatment and procedures required in such cases is a prerequisite for an adequate reimbursement. In the long-term, hospitals will only be able to offer such complex treatment forms if the financial compensation correctly reflects the costs incurred.

Wirtschaftliche Evaluation angiographischer Interventionen einschließlich einer radiologischen stationären und ambulanten Patientenbetreuung

To determine the economic efficiency of a whole-radiology in- and outpatient treatment with angiographic interventions performed as the main or sole therapy. The calculations represent the data of a university radiology department, including the following angiographic interventions (neuroradiology not considered): Vascular intervention (PTA, stent implantation) of kidneys and extremities, recanalization of hemodialysis access, chemoembolization, diagnostic arterioportal liver CT, port implantation, varicocele embolization, PTCD, percutaneous implantation of biliary stent. First, the different angiographic interventions are categorized with reference to the German DRG system 2005. Considering the example of a university hospital, the individual cost of each intervention is calculated and correlated with reimbursements by G-DRG2005 and so-called "ambulant operation" (EBM200plus). With these data, profits and losses are calculated for both in- and outpatient care. Radiologic interventions of inpatients yield a profit in the majority of cases. With a base rate of 2900 euros, the profits in our university hospital range between - 872 euros and + 3411 euros (mean: + 1348 euros). On the other hand, those angiographic interventions suitable for "ambulant operation" generate average profits of + 372 euros, if only direct costs are considered. The data of outpatient radiological interventions average between 381 euros up to 1612 euros lower than compared with profits obtained from in patient care. Once an angiographic intervention represents the major or sole therapy, German radiologists are advised to operate out- and inpatient care by themselves. In Germany, the G-DRG-system and EBM enable radiology departments to generate considerable proceeds for their hospitals and, secondly, to yield a valuable add-on profit for their own department budget, which then is partly detached from the inflexible conventional reimbursement of radiological services.

G‐DRG Version 2005: Relevante Aspekte für die Dermatologie

ZusammenfassungEin Jahr nach der obligaten DRG‐Einführung in den deutschen Krankenhäusern liegt nun die dritte Version eines deutschen DRG‐Fallpauschalensystems vor, die sich wiederum sehr deutlich von der Vorgängerversion unterscheidet. Die Veränderungen am Klassifikationssystem sowie die Einführung weiterer Zusatzentgelte tragen dabei zu einer verbesserten Abbildungsqualität vieler Leistungsbereiche bei. Ein großer Teil der bekannten und wiederholt diskutierten Probleme wurde konstruktiv angegangen und Vorschläge bezüglich der Sachgerechtigkeit der Leistungsabbildung umgesetzt. Hierbei sind unter anderem die modifizierten Algorithmen der Hauptdiagnosekategorien und die verstärkte Berücksichtigung von Komplikationen, Begleiterkrankungen und/oder multiplen Prozeduren zu nennen. Es kann allerdings nicht erwartet werden, daß mit der neuen Version die Probleme in der Abbildung spezialisierter Leistungen bzw. die noch bestehenden Probleme der Dermatologie umfassend gelöst wurden. Insgesamt ist aber ein großer Fortschritt bei der Systemgestaltung zu verzeichnen. Die wesentlichen Aspekte der G‐DRG Version 2005 und der begleitenden Abrechnungs‐ und Ausführungsbestimmungen werden mit Blick auf die Dermatologie erläutert.

Analyse von Patienten mit hohen Fallkosten im Patientengut einer HNO-Klinik der Maximalversorgung und ihre Refinanzierung durch das G-DRG-System

With the introduction of a diagnosis related groups (DRG)-system in Germany, the medical analysis of the total costs of caring for a given patient is of significance. The medical identification of cost intensive patients becomes of increasing importance for the financial perspective of a department, because the averaged lump sum system might not break even these treatments. In the Department of Otorhinolaryngology, University Ulm, a tertiary referral center, the 56 most expensive patients from 3131 inpatients which were treated in 2002 were retrospectively identified and expenses for diagnostic tests, therapy and post-operative complications were analyzed. All patients' related costs, including all costs for personnel, were assigned to a DRG (Version 1.0 G-DRG and G-DRG 2004). The most expensive treatments included extensive tumor surgeries, surgery of the trachea, emergency procedures and reconstructive surgery. Costs increased with complications, prolonged stay in the intensive care unit and simultaneous internal diseases. The cost at our institution for an pharynocutaneous fistula added 3000 Euro. The assignment of treatment costs to a DRG is complex. Based on our data extensive surgeries for head and neck malignancies showed a homogeneous cost distribution in the DRG group of G-DRG 2004 which was however inadequately reimbursed. Detailed prospective analyses from multiple centers to identify expensive treatments in the field of otorhinolaryngology are necessary to incorporate modifications into the German DRG-system.

Änderungen des G-DRG-Systems von 2003 bis 2005 in der Augenheilkunde - Ophthalmologische G-DRGs von 2003 bis 2005

The objective of the study was to illustrate the effect of the extensive changes of the German DRG System on reimbursement of clinical ophthalmology during the years 2003, 2004 and 2005. All ophthalmologic patients treated as in-patients at the Department of Ophthalmology at the University Munich during the year 2003 served as a reference data basis. By means of appropriate software those cases were then re-grouped according to the G-DRG classification of the years 2003, 2004 and 2005. This resulted in different reimbursements caused only by system changes for an exemplary hospital of maximum medical care. In addition, the same calculations were performed for four virtual, typical clinics based on the calculation data of the "Institut für Entgeltsysteme (InEK)". For those four clinics it was assumed that 80 % of the cases came from one of the subspecialties retina, glaucoma, cataract or strabismus surgery. Changes in the G-DRG system caused the sample hospital of maximum care to loose 8.5 % case mix index (CMI) during the period of 2003 to 2005. For three of the four virtual, typical ophthalmological clinics the theoretic reimbursement conditions also deteriorated: retina surgery -- 10.6 %, glaucoma surgery - 15.8 % and cataract surgery -- 17.9 % CMI. Only strabismus surgery showed an increase of + 5.6 % in CMI during the period examined. Over the years 2003 to 2005 the CMI clearly deteriorated for many ophthalmological subspecialties given otherwise identical conditions. To calculate the changes specifically for an individual hospital, the individual base rates have to be considered.

Neurological Departments and the German DRG-System for 2006

Am 8.9.2005 einigten sich die Partner der Selbstverwaltung über das G-DRG-System für 2006 (z. B. unter www.g-drg.de). Struktur und Kalkulation beruhen auf den Daten von über 2,5 Millionen Behandlungsfällen aus dem Jahr 2004. Das System umfasst 954 DRGs (+ 76), von denen 40 nicht bewertet und ggf. zu verhandeln sind sowie 40 bewertete und 42 nicht bewertete Zusatzentgelte.

Implementierung einer internen Leistungsverrechnung �ber An�sthesieminuten

Internal transfer pricing system (ITPS) of anaesthesia services is established to guarantee a close connection of delivered service and the budget of the department of anaesthesia. In most cases a time-based system is used with the pricing unit being calculated as the quotient from the enumerator "costs" divided by the denominator "anaesthesia time in minutes". The implementation of a transfer pricing system requires the identification of all relevant costs caused by the department of anaesthesia and a cost centre structure is needed which allocates all costs correctly according to their cause. The regulations regarding cost calculations as defined by the German DRG System should be considered. To generate valid data not only the necessary technical infrastructure is needed, but also detailed training of the staff and plausibility checks are needed to ensure correct and complete data. Subsequent agreements with the hospital administration are necessary in order to adjust the system if extrinsic cost increases occur. This paper gives a step-by-step guidance for the successful implementation of an internal transfer pricing system based on anaesthesia time.

Diagnoseorientiertes Fallpauschalengesetz f�r Krankenh�user (DRG)

The implementation of the new system of hospital care, "G-DRG 1.0", has many problems. The responsibilities and demands of the introduction of DGRs are given from the standpoint of a university hospital, together with the demonstrated systematic errors and pitfalls within the current version the German DRG system. The deficits of the procedure for the calculation of the cost weighting are also outlined. Finally, the needs and critical issues of the new financing system will be targeted in the context of further DRG-development and hospital related long-term planning.

Further development of the German DRG system--the position of the German Society for Rehabilitation of the Disabled

Further development of the German DRG system--the position of the German Society for Rehabilitation of the Disabled