The future of cross-sector care: the potential of hospital reform for outpatient surgeries and procedures

Two areas must play a key role in the current discussion about efficient networked care between the inpatient and outpatient sectors. The current lowest level of care in the intended hospital reform is considered - the so-called Level Ii of integrated outpatient-inpatient care as well as the area of sector-equivalent care and remuneration in accordance with Section 115 f
SGB V. Both areas have the potential to play a far-reaching role in the context of medically high-quality and efficient patient care, but are not associated with much value in the current legislative process. The aim of Section 115 f SGB V is to ensure uniform, sector-level remuneration for certain services in the area of outpatient surgery (AOP catalog in accordance with
§ 115 b SGB V). However, only a few intervention figures will probably be taken up by the Federal Ministry of Health (BMG) in the first draft of a legal regulation. This would only make rudimentary use of the company's own scope for developing outpatient surgery - i.e. more or less putting a tick on the coalition agreement.

>> In public interpretations (Ärzteblatt 2023; BMG key points paper 2023) on the newly defined levels discussed as part of the hospital reform, the planned lowest level of cross-sector care is judged to be groundbreaking, but reduced to basic care and day care and thus as a presumably less profitable area declared.
However, the legislative design of both areas plays an important role. With a sensible alignment of the level of cross-sector care, in particular to a substantial range of services defined in Section 115f SGB V, the course could be set for making progress in the field of outpatient care in an internationally comparable manner. Particularly in the area of outpatient surgery, it is possible to access high-quality and efficient care, which has long been the international standard (Simon et al 2023; Schreyögg 2023).
This article is dedicated to the question of what potential can be identified in the level of integrated outpatient-inpatient care of the announced hospital reform for the further development of the large area of outpatient operations. The answer to the question results from analyzes of the promotion of outpatient surgery in the field of orthopedics and trauma surgery, which are then weighed against the current status of hospital reform. A corresponding recommendation for this area is derived from the result.
The hospital reform: intended reforms of inpatient care
changed compensation structures
The planned hospital reform aims to bring about far-reaching changes in the German hospital landscape and patient care. A changed model for hospital financing should be accompanied by nationwide requirements for the implementation of hospital planning at the state level. In the future, the financing of operating costs should no longer be based essentially on DRGs, but rather be converted to a mixed remuneration, the so-called 2-pillar model “Provision and DRG” (Government Commission 2023).

Hospital level
Since the planning of hospital care, which is characterized by the federal system, falls within the competence of the states, there has been no nationwide uniform definition for different levels of hospital care. The government commission's first proposal for a hospital reform planned to differentiate between three levels of care nationwide, but a corresponding agreement could not be reached between the federal and state governments. A categorization according to hospital level could fictitiously take place at the federal level, but the actual planning sovereignty would still remain with the states (Ärzteblatt 2023a). Only for Level Ii (according to the federal states’ ideas of “cross-sector suppliers”) have concrete specifications been agreed upon.
Level Ii hospitals will in future play a special role in the further development of cross-sectoral and integrated health care, which has long been discussed in Germany and is urgently needed. It should be crucial for hospitals at this level that they can be adapted to regional conditions in order to ensure care close to home. For example, a design as a regional health center with acute care beds could also be conceivable.
Due to the planned cross-sectoral nature of this level of care, the service framework to be provided will also differ accordingly from hospitals at higher levels of care. In addition to the basic inpatient care obligations mentioned, hospitals at a cross-sector level should primarily provide the following services on an outpatient basis:
• Outpatient operations according to § 115 b SGB V
• Sectoral provision of services in accordance with Section 115 f SGB V
• Outpatient services based on authorization from a statutory health insurance provider
• Attending medical services
• Services from institute outpatient clinics
• Care services, both according to SGB V and SGB XI (especially transitional care)

In addition to the form of service provision, Level Ii hospitals should also be differentiated from hospitals at higher care levels based on the remuneration system. A mixed remuneration consisting of maintenance fees and the DRG system is provided for all higher hospital levels. For Level Ii hospitals, a financing mix should be created based on the applicable billing systems. Outpatient operations, for example, will continue to be remunerated using the uniform assessment standard (EBM), services in accordance with Section 115f SGB V via the planned flat rates for the same sector, or inpatient services via daily rates. In the long term, uniform, sector-equal remuneration is required for all performance areas.
The basic understanding of this level is - fictitious or binding - a basis for the following analysis regarding the economic impact of a sustainably implemented area of cross-sector care.

Performance areas and performance groups
Another central component of the hospital reform is the introduction of defined service groups. Performance groups should replace specialist departments with DRG remuneration systems. They structure the treatment within a group according to appropriate qualifications and skills, but also similar technical equipment. Specific minimum structural requirements are defined: e.g. B. which related specialist areas should still be available within a service group, the minimum number of specialist medical staff, equipment to be kept available, and minimum quantity requirements if necessary. The quality requirements should be defined nationwide and only hospitals that meet the structural and qualitative requirements will be authorized to provide services and bill them. According to the BMG, it was planned to assign a specific nationwide care level (I-III) to each uniform performance group on a state-by-state basis. However, since no agreement has yet been reached in the negotiations regarding level allocation, it is currently unlikely that levels and performance groups will be linked.
In principle, there is a consensus between the BMG and the states when introducing the performance groups. The aim is to be based on the performance group model from North Rhine-Westphalia. The 64 somatic performance groups should initially only be expanded to include five performance groups. According to recent agreements, the responsibility for defining and further developing the performance groups should in the future be carried out by mutual agreement between the BMG and the states.
Current status of the legal regulation according to Section 115 f SGB V - sector-equal care and remuneration
With the adoption of the Hospital Care Remuneration Act (KHPflEG) in December last year, special sector-level remuneration for certain services was provided for the first time. The main aim of the regulation is to create uniform remuneration for selected services from the catalog for outpatient operations (Section 115 b SGB V). In particular, services with a high number of cases, a short length of stay for patients and a low level of clinical complexity should be taken into account. In fact, this legislative initiative was intended to gradually close the large gap between the internationally established range of outpatient operations and the situation in Germany.
These very ambitious ideas of the legislator will probably only be concretized in the form of a rudimentary volume of interventions to be carried out on an outpatient basis within the framework of the legal regulations. It was originally planned that the contracting parties of the self-administration, the National Association of Statutory Health Insurance Physicians (KBV), the National Association of Statutory Health Insurance Funds and the German Hospital Association (DKG), should reach an agreement by March 31, 2023 regarding the special sector-level remuneration for procedures and operations. However, since no agreement has been reached between these partners, the authorization to issue ordinances in accordance with Section 115f Paragraph 4 SGB V of the BMG is now intended to regulate the scope and calculation of the services.
Various suggestions have been submitted to the BMG. In addition to the drafts from the self-governing partners, there is also a scientific analysis dedicated to the orthopedics and trauma surgery (OuU) specialist group (Arnegger et al. 2022; Arnegger et al. 2023).
Sector-equal care and remuneration for orthopedics and trauma surgery - Section 115 f SGB V: the Wiesbaden model
Based on the requirements of Section 115 f SGB V, analyzes were carried out and a comprehensive, special sector-level remuneration model - hereinafter referred to as the Wiesbaden model - was developed (Arnegger et al. 2022)
Treatment priorities based on a total of eight less complex DRGs were generally considered for outpatient treatment (see Table 1). The approach has the potential to separate the spectrum of entire treatment focuses from inpatient billability.
In order to submit a proposal that complies with Section 115 f of SGB V, the surgical procedure codes (OPS) associated with these treatment priorities were determined using the DRG grouper and the manuals of the Institute for the Hospital Remuneration System (InEK). The DRG's level of remuneration was determined based on the average length of stay (ØVWD). The number of cases and the billing volume for the selected OPS could then be recorded as follows. In the outpatient area in accordance with Appendix 2 of the Uniform Assessment Standard (EBM), the number of cases and the billing volume of the Central Institute for Statutory Health Insurance (Zi) were used. For the area of outpatient surgery (AOP), the data from AOK Baden-Württemberg (around 4.5 million insured people) for 2019 were used and expanded to cover the entire population.
In this way, the number of total cases and the remuneration in all three areas - inpatient and contract medical service provision as well as outpatient surgery - could be determined in accordance with the AOP catalog in the hospital. For the calculation, the EBM and AOP cases were also placed in relation to the total number of billing cases from the inpatient area (DRG cases) in order to determine the level of outpatient care. Based on the requirements of Section 115f SGB V, an initial price could be calculated between the current EBM revenue and the previous DRG flat rate, weighted according to the previous level of inpatient or outpatient service provision (1).
Orthopedics and trauma surgery (OuU) is probably the most extensive area within sector-equivalent care and remuneration. This system of sector-equivalent care and remuneration for orthopedics and accident surgery can also form the basis for other specialist groups. What is more interesting for this study is the link between this analysis and the design of the range of services provided by the so-called cross-sector providers (Level Ii).
An intersectional consideration makes the concrete potential of sector-level care and remuneration in Section 115f SGB V and the integrated care level Ii of the planned hospital reform visible.
Potential of the cross-care sector – hospital level 1i
In communication with the professional public, the new hospital sector II is perceived as controversial and, above all, unattractive in monetary terms. Flexibility should ensure the right of initiative to define performance for the first time
groups by both federal and state governments. Furthermore, a negative list of inpatient services should be created that should not be provided in so-called Level II hospitals. The analysis presented below also takes this new system into account, which shows that Level Ii will have significant implications, especially in the area of outpatient operations.
In order to reveal this potential, an intersection is formed from the knowledge available on hospital reform at the time of the analysis as well as from the development of the Wiesbaden model for sector-equal care and remuneration in accordance with Section 115 f SGB V.
As of the status quo, there is no official list of service groups initiated by the BMG for the hospital reform. Therefore, as intended by the BMG, the systematics of the North Rhine-Westphalia hospital plan was analyzed and used for this study. Table 2 initially shows an example assignment for the OuU area. This includes a total of 12 hypothetical performance groups, which are in turn divided into 27 subcategories, including: B. primary endoprosthetics, revision endoprosthetics, but also simple and conservative interventions on joints and the shoulder. The hospital reform currently includes significantly fewer service groups in the area of knee and hip arthroplasty as well as conservative spinal procedures. Nevertheless, the following assignment can serve to assess the economic impact of Level Ii in connection with the consistent implementation of outpatient surgery (Table 2.)
In a first step, all DRGs and their billing volumes from the area of diseases and disorders of the musculoskeletal system (MDC 08) were assigned to this grouping. In total, around 2.6 million cases were identified in this partition of the OuU area in 2019. The billing volume for these cases amounted to around 13.5 billion euros.
Table 3 shows how the less complex treatment focuses previously relevant for outpatient treatment in accordance with Section 115f SGB V can be applied to this experimental assignment to possible performance groups (Table 3).
An evaluation of the fee volume from the area of outpatient operations in accordance with Section 115 b SGB V was also added to the DRG billing. This survey based on figures from AOK Baden-Württemberg could not be carried out initially for all DRGs. However, the available figures for the relevant OPS provide an overall overview of the fee volume that could be assigned to level Ii in the area of outpatient operations and procedures alone.
Based on the pre-Corona case numbers and the billing volumes from 2019 (source InEK data browser), in the area of outpatient operations for orthopedics and trauma surgery alone, the present analysis basically shows a potential of 950 million euros (2). The associated services should no longer be provided in hospitals with higher care levels in the future, under the premise that they can be compared internationally as part of outpatient surgical procedures.
Conclusion
Create sustainable care structures through a strong connection between hospital level Ii and sector-level care and remuneration.
Even if the planned hospital levels under current conditions
points of view probably not
come into play, the following graphic (see Fig. 1) can still provide an overall view of how areas of outpatient service
can be specifically classified into the new care context.
Sector II of outpatient-inpatient care structures (cross-sector providers) has great potential to provide very efficient and high-quality care. In addition to existing, process-optimized outpatient surgery centers, Level Ii can be able to expand and professionalize the range of outpatient operations.
In order to appropriately incentivize a new structure (Fig. 1), investments in the area of outpatient operations are necessary. At this point in time, there is widespread agreement that a level of cross-sector care will be integrated into the hospital reform and that a not insignificant proportion of hospitals will belong to this level. In the future, these hospitals will be able to make a significant contribution to the care of patients in the area, supplementing primary care.
From the present analysis it can be deduced that the hospitals with the lowest level of care in the field of orthopedics and trauma surgery already have a turnover volume that makes internal restructuring measures possible and worthwhile. The prerequisite for this is that the legislator and the self-governing partners set an adequate level of remuneration across the sector. There is also significant supply and sales potential. B. in cardiology or in the field of vascular or plastic surgery.
For the further development of outpatient operations, the existing equipment and personnel resources of the hospitals that are intended to provide cross-sector care can be used in order to finally catch up with international developments in outpatient care.
In terms of patient care, it would also be economically fatal, due to seemingly advantageous forms of remuneration or other reasons, e.g. B. to force higher levels of planned hospital structuring for existing hospitals from a local political perspective. There will be hospitals that will no longer be intended for higher levels of care with their existing range of services.
In an aging society, the houses that offer integrated outpatient-inpatient care (Level Ii) in particular have high long-term care potential combined with a promising sales volume and the opportunity to use existing resources in a more targeted manner. An essential advantage for the further development of our healthcare system as a whole. <<