Shift effects between inpatient and outpatient sectors
Medical progress and changes in medical care structures result in a changed division of labor between practicing physicians and acute inpatient hospitals. Increasingly, outpatient doctors are also providing medical services that previously required an inpatient stay - such as dialysis or lens operations on the eye. This results in a shift of services from the inpatient to the outpatient care sector, which generates “new” services in the outpatient sector. In the context of this work, these services will be referred to as “station-replacing” services and will be specifically analyzed. In addition, other services can be relocated; namely those that can in principle be provided in both sectors, but are increasingly being provided on an outpatient basis as inpatient care structures are dismantled and due to lower costs. This type of power shifting is not examined in this work.
The reason for this presentation is the intention to make shifts in services from the inpatient to the outpatient sector of the healthcare system the subject of contractual medical requirements planning (von Stillfried/Czihal 2015). Shifts in services can be seen in the fact that increases in statutory medical services are particularly visible where a corresponding decrease in inpatient billing and occupancy days is calculated, which was shown for certain diagnoses when outpatient services increased (Czihal et al 2013). A further development of this approach would be conceivable, for example with a presentation of billed services for cases with the relevant diagnoses. In this way, the scope of relocated services could be specified and calculated. Due to comorbidities in outpatient cases and a lack of distinction between main and secondary diagnoses in statutory health insurance billing, services for different diagnoses could be counted multiple times. Increasing outpatient service requirements are calculated for 17 of 20 ICD-10 chapters (Czihal et al 2013.). Since the increasing trend in statutory health insurance services can be found in the majority of diagnostic chapters, it would be helpful for the question to be able to narrow this down to certain “station-replacing” services.
>> In addition to a presentation of the volume and type of outpatient services replacing ward services over time, it should also be analyzed whether a decrease in the volume of inpatient services can be seen as the volume of ward-replacing services increases (taking into account general trends in care).
Material and method
Recording station-replacing services: Based on a theoretical discussion, various services from the uniform assessment standard were declared as potentially replacing stations. The uniform assessment standard specifies the billing and remuneration of contractual medical services, supplemented by KV-specific services, in approximately 30,000 fee schedule items. A priori, new services in the EBM are considered to potentially replace a ward and are analyzed in terms of content and, if necessary, declared to replace a ward. The introduction of new service content is seen here as strengthening the outpatient sector and thus indirectly replacing the ward.
In several respects, newly introduced contract medical services can be viewed as replacing ward services (Fig. 2). The additional financial resources for these services can be seen as strengthening the outpatient sector. An example is the surcharges or flat rates for basic specialist medical care introduced in 4/2013, which are due if the practices in question provide certain services defined as basic care. The agreement by the self-government to raise additional financial resources for this purpose ensures the existence of primary care practices and their ability to treat cases as a substitute for ward (National Association of Statutory Health Insurance Physicians 2013).
In a narrower sense, newly introduced services can be viewed as replacing inpatient care if their service content makes inpatient treatment unnecessary or less costly. For some of the newly introduced services presented here that require the most power, the following considerations should be made in this regard:
01211 Additional flat rate for willingness to visit
The flat rate can be billed in addition to the emergency flat rate according to GOP 01210 for “maintaining the constant availability of medical visits for outreach activities in the emergency (emergency) service”. It can therefore be attributed to a ward-replacing effect, as in this way hospital admission of patients can be avoided.
01435 General practitioner/specialist on-call fee
The GOP is billed for telephone consultations with contracted doctors without personal doctor-patient contact. It is therefore more likely to be viewed as an indirect replacement for inpatient care, because the willingness of practices to make telephone contact may prevent inpatient admission.
01745 Early detection examination for skin cancer
Early detection of skin cancer can be viewed as a partial replacement for the ward. A ward-replacing effect occurs when skin cancer is discovered that requires outpatient treatment. However, the early detection examination can also lead to skin cancer findings, which result in inpatient treatment.
01771 Surcharge in connection with the GOP 01770
This and the following GOP 01776 are part of the maternity care in the EBM. This preventative service cannot be classified as a ward replacement from the outset, as it is impossible to predict to what extent the findings from the relevant examinations will lead to patients being admitted.
01776 Pre-test for gestational diabetes
The same applies here as for GOP 01771.
03362 Family doctor-geriatric care complex
The complex is being introduced to care for geriatric patients who require particularly complex care due to the nature, severity and complexity of their illness (KBV 2013). It can therefore be expected that hospital admissions that would otherwise be necessary for these patients will be avoided.
04355 Social-pediatrically oriented in-depth advice, discussion and/or clarification
The GOP can be charged for certain diagnoses without the benefit content being explicitly related to outpatient or inpatient treatment. It is therefore unclear whether the advice leads to the avoidance of inpatient admissions.
16233 Additional flat rate for co-care of a patient with a disease of the central nervous system in the home environment
The possibility of billing for patient care in the home environment introduced with this GOP leads to the expectation that inpatient stays of these patients will become unnecessary to a certain extent.
30790 Initial diagnostics and final examination for treatment using body acupuncture; 30791 Carrying out body acupuncture
The introduction of this GOP expands the options for billing pain therapy according to the uniform assessment standard. Pain therapy according to EBM was already partially provided on an outpatient basis before acupuncture became billable. The GOP is therefore more likely to indirectly replace a ward, as long as it avoids admissions that would result from pain symptoms if acupuncture were not performed.
Macular degeneration treatment, macular edema, choroidal neovascularization (GOP 93783-93792)
The services are usually carried out on an outpatient basis, only in the case of macular surgery are they usually carried out on an inpatient basis (Professional Association of Ophthalmologists 2011). Since the service texts of the GOPs concern intravitreal medication injection and not macular surgery, it can be expected that its outpatient provision will replace inpatient treatment.
The selection also includes all services in accordance with the tripartite contract for outpatient surgery and other ward-replacing procedures (AOP contract) in accordance with Section 115b Paragraph 1 SGB.
The GOP selection of station-replacing/new services then includes 4234 GOP, including 2583 GOP numbers 40000ff, i.e. flat-rate costs and KV-specific services, in particular from the following service areas (Fig. 3).
The use of the inpatient sector is determined by the number of calculation and occupancy days. The change in these components over time is recorded. Evidence of performance shifting is likely to exist if one or both of these components decline over time.
For the intended correlation with outpatient ward-replacing services, the trend can be formed not only for all inpatient occupancy days, but also for the subset of outpatient-sensitive hospital cases with the 13 indications defined for this purpose. The idea is that the shifts analyzed here will trigger a downward trend in the number of occupancy days for these indications in particular.
The 13 indications in question are defined by both three-digit and four-digit ICD-10 code numbers (Albrecht M et.al. 2014). Since the DRG statistics for the years 2011 to 2013 are only available with three-digit ICD-10 code numbers, the definition of the indications is approximately implemented here as follows:
During the evaluation, certain filters cannot be used that are not included in the evaluated data, e.g. “short-term residents” or “self-admission”.
The scope of ward-replacing contractual medical services is calculated from the service requirements, i.e. the fee requirements of the practices to the Association of Statutory Health Insurance Physicians. The database used is the billing statistics of the National Association of Statutory Health Insurance Physicians (VDX data) for the years 2009 to 2014.
For outpatient operations and other ward-replacing procedures (AOP contract) in hospitals, there is no data source available that contains information on the individual services. The total number of outpatient operations according to §115b SGB V was around 1.9 million in 2013 (basic hospital data). The number of benefit cases in question is given as 1.7 million (KG 2 statistics).
The inpatient service volume is quantified with inpatient occupancy days for outpatient-sensitive hospital cases. Since these are only available in the form of “DRG statistics” from 2011 to 2013, the trends in the outpatient and inpatient sectors are compared with information from 2011 and 2013.
Results
For all selected GOPs, there is an outpatient service requirement (excluding attending physicians) of 6.6 billion euros or 27.2 % in 2014
more than in 2009. The increase is above average compared to the increase in total power requirement of 11.3 % in the same period (Fig. 4).
As already mentioned, some of the new services selected here can be viewed as indirectly replacing ward services, namely as strengthening the outpatient sector through additional financial resources. An example is the surcharge for treatment by a conservative ophthalmologist (GOP 06225), which is included from 2013. A significant part of the increase (264 million euros) is due to the service requirements of this ophthalmological supplementary GOP (Fig. 5). The surcharges for basic specialist medical care introduced in 4/2013 continue to be seen as indirect ward replacements, including the GOP 08220 surcharge for basic gynecological care with the highest increase in service requirements.
Other selected GOP are to be seen as ward replacements in the narrower sense, such as GOP for dialysis flat rates, family doctor-geriatric care complex, additional flat rate colonoscopy, as well as intraocular or dermatosurgical procedures as well as human genetic services. These ward-replacing readings in the narrower sense will be correlated below with outpatient-sensitive hospital cases.
If one filters out the subset of outpatient-sensitive hospital cases from all hospital cases, the corresponding occupancy days increased by 3.5 % on average from 2011 to 2013, contrary to the downward trend in the average of all hospital cases (Fig. 6). The increase is primarily due to increasing days of occupancy in cases of pneumonia, chronic obstructive pulmonary disease, acute bronchitis, volume depletion and heart failure.
From 2011 to 2013, the national average total outpatient service requirement increased by around 4.6 % (crude rate, Fig. 7).
If you fictitiously set the average outpatient service requirement per inhabitant1 constant at the value from 2011, an expected service requirement for 2013 can be calculated, which results from the development of the average age of the population. This results in an expected performance requirement that is 0.3 % higher than in 2011. This results in a demographically adjusted performance requirement that is calculated to be 4.3 % higher than 2011.
The national average of occupancy days fell by 0.5 %. An expected increase due to demographic development of 2.5 % results in a demographic-adjusted decline of 3 %.
The subset of the outpatient service requirements of selected ward-replacing/new GOPs also increased on average from 2011 to 2013 (crude rate around 4 %, Fig. 8). The expected performance requirement for these services is 1.4 % higher than in 2011. This results in a demographically adjusted performance requirement that is calculated to be 2.6 % higher than in 2011.
If you filter out the subset of outpatient-sensitive hospital cases from all hospital cases, the corresponding occupancy days increased by a national average of 3.5 %, contrary to the downward trend on average for all hospital cases. With an expected increase due to demographic development of 3.7 %, this results in a demographic-adjusted decline of 0.2 %.
Adjusted for demographics, there is an increasing need for ward replacement/new services while at the same time a decline in the number of days occupied by outpatient-sensitive hospital cases, which can be seen as an indication of a shift. This constellation can be found in 138 of 402 circles (Fig. 9, quadrant IV). In 132 districts, an increase in occupancy days is visible as power demand increases. The distribution of the districts shows a weak correlation with regard to the two trends of outpatient service requirements for ward replacement/new services and occupancy days.
The trend constellation of increasing power requirements for station replacement/new services with a simultaneous decline in occupancy days is shown in the following figure in the four-field table “Trend constellations” at the bottom right with the color tone that can be seen there, which marks the relevant circles (Fig. 10).
As already explained, the flat rates for specialist basic medical care are more likely to be viewed as services that indirectly replace ward care, since these are due when the practices in question provide certain services defined as basic care and thus ensure the existence of basic care practices and their ability to treat ward-replacing cases. Billing data for these flat rates is available for 2013 in accordance with the introduction of the relevant GOPs from the 4th quarter of this year. In order to be able to correlate these with inpatient occupancy days, corresponding data for 2013 is available. Occupancy days for 2014 are not yet available. The comparison possible here refers to the outpatient service requirement from flat-rate basic medical care in the fourth quarter of 2013, while inpatient days of outpatient-sensitive hospital cases can be taken into account in relation to the entire year.
In 33 of the 402 districts, the average outpatient service requirement per resident from flat-rate basic medical care is above average and the days of occupancy per resident are below average (Fig. 11).
A risk adjustment of the distribution of the average outpatient service requirement makes sense because a service requirement that deviates from the actual service requirement is to be expected, which arises due to the special features in the districts compared here, which are to be viewed as relevant for the level of the service requirement from flat-rate basic medical care . For this adjustment, the result of a performance requirement calculation using the Grouper of the Institute of the Evaluation Committee based on the year 2010 is available for each district. In this way, an expected service requirement from flat rates of basic specialist medical care per inhabitant is formed by using linear regression to use the expected value according to INBA as an explanatory variable of the actual service requirement from flat rate basic medical care per inhabitant.
For each district, there is a residual as the difference between the expected and actual service requirements from flat-rate basic medical care per patient. However, the negative connection between this residual and the average occupancy days per inhabitant across the districts, which was sought as an indication of relocation effects, cannot be found.
Conclusion
The number of treatments that are carried out on an outpatient basis instead of an inpatient basis increased measurably and significantly during the study period.
Inpatient billing and occupancy days may decline not only because of the increase in outpatient services shown here. For example, treating doctors could forego admission because they are replacing therapy in the hospital with prescribed medication. This is conceivable without the statutory medical services selected here replacing the ward being provided. Corresponding indications are not taken into account with the approach chosen here and would have to be defined with medical and pharmacological expertise.
From the study plan developed, the results of the subject group average of the selected services are shown here. A continuation could be to show the average service requirement of the treatment cases per specialist group for which at least one of the selected services was billed, which is therefore made up of the service requirement of the selected GOP and all other GOP that were billed for these cases. The average service requirement of ward replacement cases (possibly with new services) could be compared with the average service requirement of all cases per specialist group in order to see whether this differs in a relevant way. This continuation would have to be done in a future work.
The selection of station-replacing and newly introduced fee schedule items defined here could be used to show the scope and time course of the service requirements from these GOP in other databases. <<
