Breakthrough or standstill in outpatient inpatient services according to Section 115f SGB V?
23.05.2023 17:46
Many medical services that can actually be provided on an outpatient basis are still predominantly provided on an inpatient basis in Germany. Often at a significantly higher price. This costs a lot of money and puts a strain on the healthcare system. Politicians have recognized this and want to make up for the significant gap in outpatient care compared to other countries. Therefore, Section 115f SGB V was passed in the Hospital Care Relief Act (KHPflEG). This provides for “special sector-equivalent remuneration” that is to be paid regardless of whether the procedure is carried out on an outpatient or inpatient basis.
The National Association of Statutory Health Insurance Physicians (KBV), the German Hospital Association (DKG) and the National Association of Statutory Health Insurance Funds should agree by March 31, 2023 for which services from the catalog of outpatient surgery in accordance with Section 115b SGB V this remuneration will be provided. However, the three self-government partners were unable to reach an agreement within the given deadline. The conflicting positions of the contracting parties concerned, on the one hand, the scope and timing of outpatient care. The KBV's proposal included significantly more operations from different service areas, which could have been reimbursed with the new flat rate per case from April. The KBV had selected the services in accordance with the legal requirements - high number of cases in the hospital, short length of stay and low level of clinical complexity. The health insurance companies and the DKG, on the other hand, only wanted to start with a very narrow range of services. Now it's the Federal Ministry of Health's turn. It must determine the relevant services and specific remuneration by legal regulation.
Future of sector-level remuneration
Against this background, the Central Institute for Statutory Health Insurance (Zi) spoke with the first chairman of the professional association for arthroscopy, PD Dr., as part of its live streaming format “Zi insights”. Ralf Müller-Rath and the President of the Association of Leading Hospital Doctors in Germany (VLK), PD Dr. Michael A. Weber, discussed the future of sector-level remuneration. The focus was on the question of what is now important from the perspective of the doctors concerned in the context of the hospital or the contracted medical care.
Outpatient surgery as the key to an efficient and quality-oriented healthcare system
It became clear that outpatient surgery is consistently viewed as a key to an efficient and quality-oriented healthcare system of tomorrow. Germany is still considered one of the OECD countries with a comparatively low level of outpatient care. The pressure to act to overcome sector boundaries has also continued to increase in this country, not only against the background of growing personnel shortages, said Weber. Sector-level remuneration is now necessary so that hospitals can quickly create the necessary organizational and, in some cases, structural requirements. It is widely undisputed that outpatient surgery will have to be significantly expanded across sectors in the future. Other station-replacing services should also be included in the future.
A system of contextual consideration is needed
“We see a potential of around 2,500 medical services for the catalog of outpatient services. Since the same service can be performed on very different patients, the respective outpatient proportions differ depending on the diagnosis-related flat rate (Diagnosis-Related Group; DRG) in question. In order to maintain patient safety, a system of contextual consideration is needed. This makes it possible to decide, on the basis of verifiable illness and treatment circumstances, whether patients should be cared for on an outpatient basis, with increased care requirements, or as an inpatient. Therefore, experience should first be gained with a reasonably manageable catalog that focuses primarily on high-frequency services with a predominantly low level of complexity. What’s important is that momentum is finally coming into the system,” Weber continued.
Outpatient surgery meets the highest quality requirements
The orthopedist and trauma surgeon Müller-Rath also pointed out in the discussion the immense potential of outpatient provision of sophisticated medical care services: “Outpatient surgery has been the absolute standard for us surgeons in practice for many years and meets the highest quality requirements, even though the current statutory remuneration for this is not sufficient is. That's why arthroscopic services have been one of the most common treatments carried out on an inpatient basis for years. They could be completely transferred to the service catalog of the same sectoral remuneration - in the initial phase adjusted for the reconstructive interventions. However, we would not be able to refinance the necessary infrastructure investments with the remuneration based on the uniform assessment standard.”
Both Weber and Müller-Rath emphasized that the flat-rate remuneration for services in the same sector should not include material costs. In addition, the definition of the service content must be limited to the actual service and the period of time that is accessible to direct control by the operating institutions. Concepts according to which the scope of the flat rate includes all services provided to patients undergoing surgery post-operatively, weeks after the actual treatment, are completely unsuitable.
Incentive pricing
In the joint discussion about the prospects of cross-sectoral remuneration, the deputy chairman of the Zi board, Thomas Czihal, advocated for incentive-based pricing: “In order to promote outpatient treatment, the price difference must be as small as possible in the first few years compared to the previous inpatient implementation. According to our calculations, the remuneration for inpatient performance of services in Section 1 of the AOP catalog is on average around four times the remuneration for outpatient service provision. The highest possible remuneration for outpatient implementation will be an important incentive to promote more resource-efficient outpatient treatment. What is now important is a pragmatic start and a reassessment of the services or a recalculation of the remuneration based on empirical cost data after two to three years of experience with sector-equivalent remuneration.”