wilm quentin, m.d., msc hppf department of health care management, technical university berlin
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LSE/NHS Confederation Seminar Series 2010. Hospital Financing in Germany: The G-DRG System. Wilm Quentin, M.D., MSc HPPF Department of Health Care Management, Technical University Berlin (WHO Collaborating Centre for Health Systems Research and Management) & - PowerPoint PPT PresentationTRANSCRIPT
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25 May 2010 Hospital Financing in Germany: The G-DRG System 1
Wilm Quentin, M.D., MSc HPPFDepartment of Health Care Management, Technical University Berlin
(WHO Collaborating Centre for Health Systems Research and Management)&
European Observatory on Health Systems and Policies
Hospital Financing in Germany: The G-DRG System
LSE/NHS Confederation Seminar Series 2010
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Hospital Financing in Germany: The G-DRG System
1. Diagnosis Related Groups (DRGs): Introduction– Options for hospital reimbursement– DRGs: Patient classification + hospital payment
2. DRGs in Germany– Three phases of introducing DRGs– Current developments and options for the future
3. EuroDRG
25 May 2010 Hospital Financing in Germany: The G-DRG System 2
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Hospital Financing in Germany: The G-DRG System
1. Diagnosis Related Groups (DRGs): Introduction– Options for hospital reimbursement– DRGs: Patient classification + hospital payment
2. DRGs in Germany– Three phases of introducing DRGs– Current developments and options for the future
3. EuroDRG
25 May 2010 Hospital Financing in Germany: The G-DRG System 3
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Options for hospital reimbursement (I)
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Reimbursement Strengths WeaknessesGlobal budgets - administratively simple
- planning security for providers- no incentives for performance / productivity- no incentives for efficiency- incentives to avoid sicker patients
Per diems - administratively simple- somewhat related to resource consumption of patients
- incentives to increase length of stay- usually not adapted for performance of providers- incentives to avoid sicker patients
Undertreatment
Inappropriate
treatment
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Options for hospital reimbursement (II)
25 May 2010 Hospital Financing in Germany: The G-DRG System 5
Reimbursement Strengths WeaknessesGlobal budgets - administratively simple
- planning security for providers- no incentives for performance / productivity- no incentives for efficiency- incentives to avoid sicker patients
Per diems - administratively simple- somewhat related to resource consumption of patients
- incentives to increase length of stay- usually not adapted for performance of providers- incentives to avoid sicker patients
Fee-for-service - incentives to increase provision of services - incentives to provide all (necessary) care for all patients- allows incentivising specific services
- incentives for overvtreatment- no incentives for efficiency- cost inflation- administratively complex
Undertreatment
Inappropriate
treatment
Overtreatment
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Options for hospital reimbursement (III)
25 May 2010 Hospital Financing in Germany: The G-DRG System 6
Reimbursement Strengths WeaknessesGlobal budgets - administratively simple
- planning security for providers- no incentives for performance / productivity- no incentives for efficiency- incentives to avoid sicker patients
Per diems - administratively simple- somewhat related to resource consumption of patients
- incentives to increase length of stay- usually not adapted for performance of providers- incentives to avoid sicker patients
DRGs - reimbursement is related to performance- incentives to increase efficiency
- incentives to avoid sicker patients- undertreatment of patients possible- up/wrong-coding, gaming- tendency to increase admissions- administratively complex
Fee-for-service - incentives to increase provision of services - incentives to provide all (necessary) care for all patients- allows incentivising specific services
- incentives for overvtreatment- no incentives for efficiency- cost inflation- administratively complex
Undertreatment
Inappropriate
treatment
Overtreatment
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Group of patients with homogenous
resource consumption
= DRG
patient variablesmedical and management
decision variables
gender, age,main diagnosis, other
diagnoses, severity
mix and intensity of procedures, technologies and human
resource use
DRGs: 1st step = patient classification / grouping
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cost weight base rate=DRG reimbursement
X
patient variablesmedical and management
decision variables
gender, age,main diagnosis, other
diagnoses, severity
mix and intensity of procedures, technologies and human
resource use
Price setting under DRGs (I)
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cost weight base rate=DRG reimbursement
X
patient variablesmedical and management
decision variables
gender, age,main diagnosis, other
diagnoses, severity
mix and intensity of procedures, technologies and human
resource use
e.g. size, teaching status; urbanity; wage level
structural variables on hospital/ regional/
national level
adjustment factors
+
determinants of hospital costs
Price setting under DRGs (II)
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France: ~2,300 Germany: 1,200 Estonia: ~500
Homogenous groups(groups of cases with similar costs)
Practicability(small number of groups)
Design options for DRG systems
Conflicting aims of DRG systems
Examples:
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Hospital Financing in Germany: The G-DRG System
1. Diagnosis Related Groups (DRGs): Introduction– Options for hospital reimbursement– DRGs: Patient classification + hospital payment
2. DRGs in Germany– Three phases of introducing DRGs– Current developments and options for the future
3. EuroDRG
25 May 2010 Hospital Financing in Germany: The G-DRG System 11
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Background: German hospital sector
• Key figures (2008):– 2100 Hospitals (1780 reimbursed through DRGs)– 17 mio. cases inpatient treatment– 57 bill. € financing sum
• Dualistic way of hospital financing– Sickness funds pay running costs (budgets DRGs)
– States pay capital costs
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DRGs in Germany
25 May 2010 Hospital Financing in Germany: The G-DRG System 13
Historical Budget (2003)
Transformation
DRG-Budget (2004)
2) Budget-neutral phase
3) Phase of convergence to state-wide base rates
• Nationwide base rate
• Dual Financing or Monistic
• Introduction of DRG-like
reimbursement for psychiatric hospitals
•Selective or uniform negotiations
• Quality Assurance (adjustments)
4) Current developments and options for the future
15 %
15 %20%
20%20%
20%20%
20%25%
25%
Statewidebase rate
Hospital specific base rate
2000-2002 2003 - 2004 2005 - 2009 2010 - 2014
Hospital specific base rate
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1) Phase of preparation: Responsibilities
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Health Ministry (federal, state)
Self-Administration (DKG, GKV, PKV)
Administration
Consultation
Health Policy
Development
DIMDI (German Institute of Medical Information and Documentation)
InEK (German DRG Institute)
Goals and
Monitoring
Forming the Legal Framework
TechnicalManagement
Contribution of
Expertise
Other Institutions (HTA, quality)
Variety of Institutions (Professional medical associations, industry groups)
G-DRGSystem
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1) Phase of preparation: How to construct a system?
25 May 2010 Hospital Financing in Germany: The G-DRG System 15
Patient classification system
Data collectionPrice setting
Reimbursement rate
• Diagnoses• Procedures• Severity
• Clinical data• Cost data• Sample size
• Average prices• Cost weights
• Outliers• High cost cases
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1) Phase of preparation: Patient Classification
25 May 2010 Hospital Financing in Germany: The G-DRG System 16
Patient classification system
• Diagnoses• Procedures• Severity
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1) Phase of preparation: Data collection
25 May 2010 Hospital Financing in Germany: The G-DRG System 17
Case data for reimbursement
(§ 301 SGB V) Until July 1
Case-related performance andhospital-specific structural data
from every hospital (§21 KHEntgG) until March 31
Checked and anonymised data
Additionally case-related cost data from a sample of
hospitals until March 31
Hospitals
Sickness funds
• Checking data via their medical
review board• Paying hospital
InEK• Development of case fee
catalogue annually• checking data content
Data Centre• Collecting datasets • Checking case and cost data technically• Anonymising data
Federal Statistical
Office• Publication of data
DIMDI• Development and update of classification base (ICD -
10 GM and OPS codes)
Data collection
• Clinical data• Cost data• Sample size
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1) Phase of preparation: Price setting mechanism
• Calculation of cost weights: based on average costsof cases
• Data sample:
Cost weight of each DRG = Average costs of DRG inliers / Reference Value
25 May 2010 Hospital Financing in Germany: The G-DRG System 18
Year 2003 2005 2007 2009 2010Hospitals participating in cost data collection
125 148 263 251 253
- excluded for data quality 9 0 38 33 28- actual 116 148 225 218 225- included university hospitals 0 10 10 10 10- number of cases available for calculation
633,577 2,909,784 4,239,365 4,377,021 4,539,763
- number of cases used for calculation after data checks
494,325 2,283,874 2,863,115 3,075,378 3,257,497
Price setting
• Average prices• Cost weights
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1) Phase of preparation: Reimbursement
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LOS
Revenues
Deductions(per day)
Surcharges(per day)
Short-stay outliers
Long-stay outliers
Inliers
Lower LOSthreshold
Upper LOSthreshold
Reimbursement rate
• Outliers• High cost cases
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DRGs in Germany
25 May 2010 Hospital Financing in Germany: The G-DRG System 20
Historical Budget (2003)
Transformation
DRG-Budget (2004)
2) Budget-neutral phase
3) Phase of convergence to state-wide base rates
• Nationwide base rate
• Dual Financing or Monistic
• Introduction of DRG-like
reimbursement for psychiatric hospitals
•Selective or uniform negotiations
• Quality Assurance (adjustments)
4) Current developments and options for the future
15 %
15 %20%
20%20%
20%20%
20%25%
25%
Statewidebase rate
Hospital specific base rate
2000-2002 2003 - 2004 2005 - 2009 2010 - 2014
Hospital specific base rate
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2) Budget neutral phase: Transfer to DRG budgets
25 May 2010 Hospital Financing in Germany: The G-DRG System 21
Hospital Budget 2002 Hospital Budget 2003 / 2004
Reimbursement unit = per diem Reimbursement unit = case (DRG)
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2) Budget neutral phase: Hospital-specific base rate
25 May 2010 Hospital Financing in Germany: The G-DRG System 22
Base rate
Relative cost weightPatient characteristics
Gender, Age,Diagnoses, SeverityTreatment options
Procedures, Technologies,
Intensity
Hospital-specificX =G-DRG
reimbursement
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DRGs in Germany
25 May 2010 Hospital Financing in Germany: The G-DRG System 23
Historical Budget (2003)
Transformation
DRG-Budget (2004)
2) Budget-neutral phase
3) Phase of convergence to state-wide base rates
• Nationwide base rate
• Dual Financing or Monistic
• Introduction of DRG-like
reimbursement for psychiatric hospitals
•Selective or uniform negotiations
• Quality Assurance (adjustments)
4) Current developments and options for the future
15 %
15 %20%
20%20%
20%20%
20%25%
25%
Statewidebase rate
Hospital specific base rate
2000-2002 2003 - 2004 2005 - 2009 2010 - 2014
Hospital specific base rate
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3) Phase of convergence: Adaptation of base rate
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Base rate
Relative cost weightPatient characteristics
Gender, Age,Diagnoses, SeverityTreatment options
Procedures, Technologies,
Intensity
Hospital-specific Uniform statewide
X =G-DRG
reimbursement
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2005: 1%
2006: 1,5%
2007: 2%
2008: 2,5%
2009: 3%
+15%
+20%
+20%
+20%
+25%
€
Statewidebase rate
Hospital-specific
base rate
Winners
Losers
2004 2005 2006 2007 2008 2009
-15%(of difference)
Hospital-specific base rate
2010
-20%(of difference) -20%
(of difference) -20%(of difference) -25%
(of difference)
Reduction limit(related to pre-
vious year‘s budget)
3) Phase of convergence: Five year process
25 May 2010 Hospital Financing in Germany: The G-DRG System 25
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3) Phase of convergence: Changing cost weights
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Relative cost weightPatient characteristics
Gender, Age,Diagnoses, SeverityTreatment options
Procedures, Technologies,
Intensity
Year 2003 2005 2007 2009 2010DRGs total 664 878 1082 1192 1200Inpatient DRGs total 664 878 1077 1187 1195Range of cost weights: min.-max.(rounded)
0.12 - 29.71 0.12 - 57.63 0.11 - 64.90 0.12 - 78.47 0.13 - 73.76
Day care DRGs total 0 0 5 5 5Supplementary fees 0 71 105 127 143
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DRGs in Germany
25 May 2010 Hospital Financing in Germany: The G-DRG System 27
Historical Budget (2003)
Transformation
DRG-Budget (2004)
2) Budget-neutral phase
3) Phase of convergence to state-wide base rates
• Nationwide base rate
• Dual Financing or Monistic
• Introduction of DRG-like
reimbursement for psychiatric hospitals
•Selective or uniform negotiations
• Quality Assurance (adjustments)
4) Current developments and options for the future
15 %
15 %20%
20%20%
20%20%
20%25%
25%
Statewidebase rate
Hospital specific base rate
2000-2002 2003 - 2004 2005 - 2009 2010 - 2014
Hospital specific base rate
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DRGs in Germany: Main facts
1. Central role of self-governing bodies
2. Data driven system with annual updates
3. Detailed analysis of hospital costs
4. Seven-year process of introduction
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Hospital Financing in Germany: The G-DRG System
1. Diagnosis Related Groups (DRGs): Introduction– Options for hospital reimbursement– DRGs: Patient classification + hospital payment
2. DRGs in Germany– Three phases of introducing DRGs– Current developments and options for the future
3. EuroDRG
25 May 2010 Hospital Financing in Germany: The G-DRG System 29
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EuroDRG project
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Thank you very much!
25 May 2010 Hospital Financing in Germany: The G-DRG System 31