ASV flat rate per case

The starting point is the ICD codes mentioned in the specification of the GIT and the services described there. Since the range of services is very comprehensive, the corresponding codes from the operation and procedure code according to §301 SGB V (OPS) were determined for some exemplary services. The ICD and OPS codes were then used to determine the respective DRGs that would apply when billing for purely inpatient treatment.

It can be seen that the DRG (in this case H61B) provides flat-rate remuneration for many different treatments that occur individually or several times during a stay.

The Institut für das Entgeltsystem im Krankenhaus (InEK) publishes the average costs from the hospitals in the calculation sample for all DRGs (currently 1,200 flat rates per case). They are based on the costs for each individual case treated by these hospitals (currently about 250) in a calendar year. The costs are already broken down by the hospital into cost center groups (rows) and cost element groups (columns). Typical cost centers are "normal ward", "intensive care unit", but also "cardiological diagnostics, endoscopy" or laboratory".

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Example of a cost matrix

Costs that do not play a role in ASV have been removed from the costs:

  • Drugs
  • Intensive care unit
  • Delivery room
  • Dialysis

All remaining costs were analyzed as follows:

  • Are costs dependent on length of stay?
    • If yes, they were reduced to 0.25 days (corresponding to about 4-6 hours of outpatient specialized treatment)
    • If no, they were retained
  • Is a DRG associated with high radiology costs (e.g., radiation)?
    • If yes, were the costs retained
    • If no, length of stay-adjusted adjustment

Special issues:

  • Non-personnel costs can theoretically be billed directly to outpatients, but in practice this causes a lot of problems for both physicians and insurers
    • Therefore, the material costs from the DRG were retained
    • Thus also a coverage of the "consulting hour need" takes place
  • Investment costs are not included in the DRGs
    • However, the so-called "infrastructure costs" were taken over from the DRGs (adjusted, if necessary) in order to cover the space, energy and maintenance investment costs included therein

Since DRGs are relatively valued and carry so-called valuation ratios, the calculated costs were divided by the "reference value" used in the InEK - an amount in € that is used to normalize the calculation - and an "ASV weight" is obtained.

Multiplying this weight by the respective state prime rate yields the "ASV revenue".

Results

The following ICD codes were identified from the GIT diagnoses:

From the wealth of achievements were selected:

  • Chemotherapy
  • Irradiation
  • PEG system
  • Port system
  • Pain therapy

The following OPS resulted:

The DRG per-case flat rates were determined from ICD and OPS.

In each DRG, costs were modified, or deleted.

Example:

Modified cost matrix of DRG H61B: Red areas = costs deleted, blue = unchanged, orange = modified.

The following overview shows all theoretically achievable per-case flat rates, with the inpatient revenue, the revenue for 1 day and the ASV revenue:

The comparison with the remuneration for individual services according to EBM using ASV accounts from hospitals showed that the ASV revenues - as is to be expected with a flat rate - were sometimes higher and sometimes lower than the EBM revenues, but on average the ASV revenues are somewhat higher than the EBM revenues (basis: EBM revenues / quarter divided by visits in the quarter, since the ASV flat rate is calculated per visit).

DIscussion

It can be seen that the use of the DRG system appears to be possible and suitable for setting up a remuneration system for ASV quickly, in a largely appropriate and unbureaucratic manner.

Of course, aspects of the remuneration system need to be discussed. Together with the experts from the inspiring-health institute, the BDI has held a series of committee discussions on this subject, which have resulted in the following topics and possible solutions:

  • Case definition
    • Here 1 visit = 1 case
    • To avoid misaligned incentives, the readmission rules of the flat rate per case regulation (FPV) are applied so that a reasonable number of visits per quarter results
    • In principle, there is no quantity limit
  • Entry of the patient into the ASV
    • In principle, this is done via the lists of diagnoses published by the G-BA
    • From the G-BA came the idea of enrollment in a background discussion, other players - such as the DKG - find the diagnosis list sufficient
  • Cleanup
    • If a patient from the existing outpatient care system enters ASV, the KBV wants an adjustment to be made. After all, ASV is to be extrabudgetary and not remunerated from the existing outpatient pot.
    • This has been done to date (implemented for tuberculosis) using a historical case value per quarter on a one-time basis.
  • Team accounting
    • If the remuneration is made on a lump-sum basis, the team leader's institution receives the full amount
    • Other team physicians (e.g., radiation therapist) or consulting physicians (e.g., laboratory) will be paid separately by the team leader if they are utilized
    • This concept certainly needs to be communicated well to outpatient colleagues who have been used to individual billing (each for themselves), but according to the unanimous opinion of many participants, it holds great potential for the economic provision of services.

For practical implementation, it is now necessary to carry out regional pilot projects in order to clarify the above-mentioned questions in the context of the practical application of the DRG-based remuneration system and to be able to carry out a clean evaluation.

Summary

With the "ASV-DRG" project, the BDI together with   inspiring-health was able to show that the systematics of the G-DRG flat rates per case can be transferred relatively easily and transparently into a remuneration logic for ASV. The questions of case definition and adjustment need to be clarified. Team billing succeeds much better with the ASV-DRGs and in the actual sense of the legislator, even if purely outpatient teams that are not located at the hospital still have to adjust to the new approach.

The system can be tested in pilot projects.

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