The problem now is that if the destination is entered incorrectly from the start, no matter how wonderful the navigation system is and can guide us to the shortest and most efficient route, we still end up at the wrong destination. Beivers: “Regardless of whether we are discussing new incentives, whether we are talking about DRGs or adjusting the flat rate per case or even regional budgets, we are always going wrong if we do not first clarify which destination we are entering into the navigation system.” This would create absurd situations, where at the end of the value chain it is checked whether, for example, a hip operation went well, but at the beginning the question was forgotten to ask whether the patient even needed it - this is a question of the quality of the indication.
Then comes the need, formed by the benefits for patients and the necessary costs. The problem is that the benefit as an overall result is derived from the quality of the indication, a subjective component - the "experience service quality" - and the quality of access - the financial accessibility in terms of time and location. Although nationwide standards for quality are needed, the corona pandemic has shown that health is a regional matter. Each region must find its own, correct solution locally - but always against the background of nationwide minimum quantity standards and quality specifications.
Compensation systems should now help to drive the “GPS efficient route”. Colleague Wasem would have presented this beautifully in the jointly published WIdO hospital report, in which he would have said that remuneration systems should lead to needs-based care, but should also ensure the quality of care and the efficiency of service provision. This is supplemented by terms that economists would actually rarely use, such as “fairness towards service providers” and “fairness towards those who pay”. Beivers: “If we are fair to the service providers, we could controversially discuss whether allowances during the pandemic helped ensure that those who actually did the job were better paid or whether those who did not do the job are now better off .” But that is not the fault of those who accepted the money, but of those who provided these incentives. This should be discussed controversially in retrospect, even if it was a “decision made in ignorance” for everyone in the acute pandemic phase.
All party programs and also the coalition agreement would now say that the DRG system should be abolished or adapted in some way. Beivers: “But per-case flat rates cannot be to blame for everything, because they tried to replace a target image with a compensation system.”
In the 1990s, the DRG merely tried to bring about a structural adjustment in which there would be winners and losers through a new remuneration system and the competition would then sort it out - which, according to Beivers, "just didn't work". Simply because “a compensation system alone” cannot achieve this; “Not a single one”, also because there is no optimal compensation system. The Council of Experts had already pointed out many of the dangers of the flat-rate per-case system at the end of the 1990s.
The second, central misconception is that there is a remuneration system that can solve the structural problems, and the third is that the same price must apply everywhere for the same service. Beivers: “You act as if Germany is the same everywhere, which is wrong.” Germany is equal, that is stated in our constitution, and living conditions are also equal. But for ten euros you only get one liter of beer at the Oktoberfest, which isn't taking place, but at least ten beers at any gas station. Purchasing power parities have to be taken into account because many things in Germany are equivalent, but - don't misunderstand - they are not the same. Because regionally there are more or fewer older people, more or less multimorbid people and more or fewer younger people, the care must also be different.
What the current per-case flat-rate system has achieved despite everything and why it needs to be further developed beyond regional health budget per-case flat-rates is that it has led to a definition of services. In addition, performance transparency like we have never had before. In his opinion, per-case flat rates would not necessarily have to be used for remuneration in the future, but rather as a description of services, which could then be used as the basis for remuneration. One could also think about other options for remuneration, such as factor quantities, the number of patients treated (regional budgets) or falling back into a cost-recovery system such as care, although he is skeptical about this here too. Beivers: “We all agree that we have to move away from purely volume-dependent, sectoral remuneration and have two options as to how we can develop this further.” However, there will not be regional health budgets for the whole of Germany, and we should also be aware of this say goodbye to the idea that 100 percent of the services would have to be refinanced via DRG. Rather, there is a juxtaposition of different options, no more “one size fits all”. This certainly includes the question of how to deal with reserve budgets in the future. This question is anything but simple, because – according to his questions: “What is actually the new baseline?” or “What is the new normal?” The case mix volume from 2019 or that from 2020? Beivers: “If I were a health insurance manager, I would say we take the cases from 2020, take Covid-19 out, and calculate the maintenance costs on this basis.” But that is of no use because you first have to have a target image of what “what we want to keep and what we don’t want to keep”. If you now look at the whole thing from the service provider's perspective and take the 2019 case mix volume, you would "cement today's care" and support every hospital through the maintenance costs - which is why the right target picture is necessary first. You would have to invest “a lot of brain power” in this question alone, also to think about how regional health budgets could be used in individual regions, which would have many advantages.