The Central Institute for Statutory Health Insurance in the Federal Republic of Germany (Zi) called its congress “Cross-sector remuneration – chimera or soon to be reality?”, at which, among other things, a study by the IGES on “Perspectives of cross-sector remuneration for medical services” was presented.

>> “We don’t have a compensation system that rewards efficiency. If a service is provided by a hospital, the remuneration is many times higher than in statutory health care,” postulated MUDr./CS Peter Noack, chairman of the KV Brandenburg and member of the Zi board, in his opening speech. Although in his opinion there is technological equality in many areas between
outpatient and inpatient sectors, and the resident doctors were “better positioned” in terms of qualifications, the hospitals received “significantly more money for the same services”. This is justified by maintenance costs, but according to Noack, it “necessarily sends an economic signal to hospitals” that patients should, if possible, receive the most complex of all forms of care
to be treated and billed.
In order to analyze and raise awareness of these structural differences in remuneration at the sector border, the Zi commissioned an expert report from IGES. Even the IGES – according to Noack – would have been surprised at the differences, because it is difficult to understand why services in the same sector are paid so unequally.
The aim of the study presented was to present and explain differences in remuneration at the intersectoral interface of outpatient and inpatient care. However, the focus of the analysis was not on the possible false incentives that this results for individual providers of care services, but rather on cost differences from an overall economic perspective. The focus of the study was also on the question to what extent and in what way costs can be avoided by not (needing to) treat cases that can in principle be treated on an outpatient basis in a setting that is characterized by systematically higher costs.
According to Noack, the KV system has a concept for exactly this. “Services that can be provided on an outpatient basis must be remunerated in the same way, regardless of where the service is provided, namely in accordance with the EBM,” explained the KV boss, because this would eliminate the incentive to provide these services in inefficient structures.
In order to illustrate this, the IGES selected case studies that are characterized by clinical pictures and/or treatment procedures that can in principle be treated medically in both inpatient and outpatient settings. The reference points for the selection were both so-called outpatient-sensitive diagnoses and sector-specific treatment procedures. For the selected case studies, differences in remuneration that arise between outpatient and inpatient treatment were also shown.
When looking at the differences in remuneration determined for the five case studies, it becomes clear that the treatment of cases that are comparable in terms of their clinical picture or dominant treatment measures always incurs higher costs in the inpatient setting. However, the differences determined vary between the selected areas: the spectrum of additional costs for inpatient versus outpatient treatment ranges from just over 10 % to 16.5 times (Table 1).
A key economic cause of the cost differences is, according to the IGES report, the significantly greater resource burden on the stationary sector due to the provision of capacity. On the one hand, this concerns the maintenance and operation of structural or spatial capacities in order to ensure longer patient stays (over one night or several nights). On the other hand, hospitals would meet higher requirements for equipment, which must also be suitable for treating serious (emergency) cases. And finally, more medical, nursing and functional staff should be available around the clock and across a broader (interdisciplinary) professional spectrum. Accordingly, the cost structures of inpatient and outpatient facilities would then be very different.
As a possible solution, IGES cites a comparatively simple to implement, yet extreme option of determining the remuneration of a sector as decisive for all those who provide the corresponding care, regardless of the treatment setting (outpatient, outpatient, semi-stationary, stationary). However, such an approach inevitably leads to a deterioration in the position of at least one of the parties involved in the supply.
An alternative approach, however, would be to develop an independent remuneration for the area of “sector-equivalent” services, which corresponds neither to today's outpatient nor inpatient remuneration. A relatively simple approach would be to calculate the remuneration level from the mean or average value of the outpatient and inpatient remuneration. <<
by: MVF editor-in-chief Peter Stegmaier