Artificial cost pressure makes cardiological care more difficult
08.04.2015 21:51
Despite its successes, cardiology in Germany is struggling with growing financial problems. The reason for this is the system of diagnosis-related case groups, which means that, regardless of medical progress, less and less is paid for the same services.
“Cardiology is one of the medical disciplines that has achieved the most pleasing successes in recent years. Mortality after a heart attack has fallen significantly over the last few decades; new interventional procedures such as TAVI or the Mitraclip enable the safe treatment of even very sick patients. However, there are more and more of them,” says Prof. Dr. Stephan Felix (Greifswald), President of the 81st Annual Meeting of the German Society for Cardiology, where 8,500 active participants from 25 countries will meet in Mannheim from April 8th to 11th. “On the one hand, this has to do with the increasing age of the population, but on the other hand it also has to do with the fact that acute events such as a heart attack are less likely to result in death, but often lead to permanent damage to the heart.”
Cardiology operates in a special area of tension between patient care, health economics as well as research and teaching, emphasizes Prof. Felix: “The dimensions are enormous. With more than 2.5 million hospital cases in 2012, diseases of the cardiovascular system are the number one inpatient treatment cases. However, this creates an ambiguous situation for cardiology. On the one hand, the high contribution margin of the cardiology clinics has a very positive effect on the economic balance of the hospitals.” At the same time, however, the special features of the German billing system create a difficult situation, because the catalog effect in the DRG system causes a change in the evaluation of identical services.
Specifically, according to Prof. Felix, this means: “Clinic costs that are kept low within one year are included in the calculation of the Institute for the Hospital Remuneration System (InEK) in the following year and lead to lower flat rates and thus higher cost pressure two years later. Due to computational peculiarities, there are winners and losers among the subjects in this system. Cardiology is the biggest loser; it is coming under pressure because lower revenues are being generated for identical or improved services compared to the previous year.”
The system of diagnosis-related case groups (DRGs) is responsible for this. For example, Prof. Felix calculates that this has led to a real decline in reimbursement for drug-eluting stents, which are now the treatment of choice for most heart attack patients. The remuneration is based on determined average cost values and does not take into account whether the individual case is a more modern or an older stent.
This approach completely ignores the fact that new stents are constantly being developed, which often also bring demonstrable clinical advantages, criticizes Prof. Felix: “And they are not cheaper than the old models.” The dramatic impact of such devaluations can be seen for example, the treatment of very seriously ill patients (PCCL4) after a heart attack. In 2014, only 53 percent of the amount paid for the same service in 2013 was reimbursed for interventional treatment with two stents.
According to the expert, the aim of this system is to keep the prices for inpatient services in Germany as low as possible. According to data from the OECD, Germany, for example, is in the penultimate place of the countries examined when it comes to purchasing power-adjusted prices for coronary interventions, far behind Austria and Portugal. The USA is by far the leader in terms of prices.
Prof. Felix: “Health policy currently does not want to stop the price decline. The political goals are market consolidation, concentration, network and center formation. But can we continue to increase productivity as quickly as the cost-revenue gap requires? The hospital that needs it must be able to survive without an increase in volumes.”
University hospitals in trouble
In this system, the university clinics find themselves in a very special situation, as they are not only responsible for research and teaching, but also have to take on the care of patients with rare diseases as well as extremely complex and expensive cases, emphasizes Prof. Felix: “In addition, that the share that university hospitals take on in emergency care is increasing disproportionately. This results in increasing financial difficulties for these houses over the years. The federal government does make significant funds available for universities of excellence and health centers.” But these cannot be used for routine care and are therefore not a solution to the problem. The allocation of federal funds for research makes a lot of sense. However, this does not solve the structural problem of university medicine, emphasizes Prof. Felix: “Additional funds are absolutely necessary to finance university medicine at all locations, which are needed, for example, for emergency medicine, extreme cost cases, university outpatient clinics and investments.” This is essential in order to “To maintain high-performance medicine, to increase the competitiveness of German university medicine and to avoid the pressure to carry out unforeseen cross-financing.”