Diagnosis-related case groups

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Diagnosis Related Groups ( DRG ; German : diagnosis-related case groups ) denote a controversial classification system for a flat-rate billing process with which hospital cases (patients) are assigned to case groups on the basis of medical data. Methodological similarities, the so-called service designators, are used to determine case groups. These are, for example, main and secondary diagnoses, procedure codes or demographic variables.

DRGs have been used in various countries to control health care funding since the mid-1980s. While in most countries the DRGs are used hospital-related to distribute state or insurance- related budgets , in Germany the G-DRG system introduced in 2003 was transformed into a case-based flat rate system and has since been used to settle prices for the individual types of treatment for the individual treatment cases. Each new patient admission to hospital, rehabilitation and care department defines a new case, which characterizes further treatment. The determined DRG, with main and secondary classes, are reported by the service provider to the cost unit as the basis for billing.

In Germany, the flat rates are also calculated on the basis of the distribution of the total available budget. These case groups are assessed and billed according to the average operating expenses determined for the treatment in the previous year. The flat rates reduced to DRG represent a consensus-based allocation model. They are not used to record costs and not to determine prices based on the actual business costs of the treatment.

In Switzerland, the flat rate system SwissDRG and the associated new hospital financing was introduced on January 1, 2012. The Swiss version is based on the German DRG ( G-DRG ) system and has been adapted to the special features of the federally structured health system in Switzerland. SwissDRG AG is responsible for the development and further development as well as the adaptation and maintenance of the Swiss case flat rate system.

Basics

In the DRG system, patients are classified into case groups for billing purposes on the basis of medical (diagnoses, treatments carried out) and demographic data (age, gender and the intake weight in grams for children younger than 1 year). However, the case groups are not used to determine the medical treatment, but the differentiation is based on the typical effort (treatment costs) determined in the previous period . This case groups with a so-called review relation (Engl. (BR) cost weight (cw)) evaluated in the different treatment costs of the case group are reflected.

Flat-rate billing in individual cases

The main criteria for assigning the treatment case to a diagnosis-related case group are:

  • The main diagnosis (for GDRG: the diagnosis primarily responsible for hospital admission from the retrospective, often the underlying disease),
  • procedures carried out in the hospital (operations, complex examinations),
  • Secondary diagnoses and complications that have a significant impact on the course of treatment (by taking into account an expense),
  • the ventilation time and
  • patient-related factors such as age, gender of the patient or the birth or admission weight in premature babies and infants.
  • as well as length of stay, type of admission (transfer, briefing) and type of discharge (transfer, death ...)

The following key systems are used in connection with the DRG in Germany:

Doctors and nursing staff in German clinics are increasingly dependent on the help of specially trained specialists due to the workload as well as the growing complexity and development of DRGs, ICD and OPS. This should ideally combine a combination of medical background knowledge, advanced knowledge of the DRG system, business expertise and practice-oriented IT skills. In order to meet the significant billing and medical requirements, further training for medical specialists or suitable billing staff to become medical coding specialists has been established. Here, graduates can acquire a certificate from the Chamber of Commerce and Industry as proof of qualification. A structured training standard has been established since 2013. Specialists who are already working in the professional field can, if they are suitable, obtain the IHK certificate as part of a qualification test.

history

Development in the United States and Australia

DRG were developed in the USA at Yale University by Robert Barclay Fetter and John Devereaux Thompson from 1967. Originally, however, they were not developed as a reimbursement system, but as a pure patient classification system which, as a management tool, should enable the measurement, evaluation and control of treatments in hospitals.

The solutions used and developed today were used for the first time from 1983, for example, as a prospective remuneration system and for recording the remuneration claimed in the Medicare program in the USA ( accounting ). In Australia , the first version was released in 1992 in the state of Victoria. This version served as a reference for the implementation of a similar solution in Germany.

In the USA, DRGs were initially used to classify medically similar patient groups, and only later did they become remuneration systems based on the assessment of the severity of the treatment and the reference to the typical costs. This resulted in a shift in the proportion of inpatient services to outpatient services. The American DRGs of the Centers for Medicare & Medicaid Services (formerly the Health Care Financing Administration , HCFA) are applied in full only to the population over 65 years of age insured through the state Medicare program.

The concept of DRG was originally designed by Fetter and Thompson from 1967 onwards to control clinical services and to measure the performance and quality of medical service. The control aspect ( scheduling ) contained at the beginning has been lost in all solutions known internationally today.

Adaptation in Germany

The self-governing bodies of the German health care system were asked by politicians in 2000 to select an existing DRG system as the basis for the German system to be established. The decision was made in favor of the system of the Australian state Victoria , called 'Australian Refined Diagnosis Related Groups' (AR-DRG). An adjustment to the German treatment reality is to be achieved through revision at annual intervals. The institute for the remuneration system in hospitals (InEK GmbH) in Siegburg, founded in May 2001, has been commissioned with this . Since the first definition of the DRG method, there has been no scientific evidence, neither in the country of origin, the USA, nor in Australia, which is regarded as a model, nor in Germany that the method curbs health care costs. At most, there is a delay in the increase without changing the dynamics.

Criticism in Germany

The German DRG system has been criticized since it came into force in 2003, among other things, because it led to the commercialization of the health system and the associated significant increase in the workload of nurses and doctors. Heidrun Grid, the Vice President of the German Medical Association, judges the flat rate case system as "bad for patient safety". Günther Jonitz, President of the Berlin Medical Association, had previously stated that, in contrast to Australia, "in Germany, the DRGs had not been implemented from the beginning to optimize but rather to decimate hospitals". "The DRGs were not fully funded from the start and central areas such as personnel development costs are completely missing." As Boris Augurzky from the RWI - Leibniz Institute for Economic Research criticizes, the DRG system encourages treating as many inpatient cases as possible, and so " into a hamster wheel ”.

Circumvention strategies

The so-called pre-clinics , which have meanwhile been introduced at some hospitals, do not carry out any triage or initial assessment, but rather confirm or correct the diagnosis of admission to the structured flat-rate billing procedure. Formally, when the patient leaves the pre-clinic and is admitted to the normal clinic, regardless of the admission diagnosis, it is classified as a new case and economically appropriate to the specified, structured, flat-rate billing process.

Adaptation in Switzerland

In December 2005, the responsible body in Switzerland decided to introduce a DRG system based on the German model. The SwissDRG emerged from the process of Helvetization (adaptation to the reality of Swiss treatment).

See also

literature

  • R. Bartkowski, H. Bauer, J. Witte: G-DRG practice commentary on the German case flat rate system. ecomed medicine, 2007, ISBN 978-3-609-10500-0 .
  • Wolfram Fischer: Diagnosis Related Groups (DRGs) and care. Basics, coding systems, integration options. Huber, Bern 2002, ISBN 3-456-83576-0 .
  • Jens Flintrop: Effects of the DRG introduction - economic logic becomes the measure of all things. In: Deutsches Ärzteblatt. 46 (2006), 3085 ISSN  0012-1207 online edition
  • Peter Indra: The introduction of the SwissDRGs in Swiss hospitals and their effects on the Swiss healthcare system. Publishing house Switzerland. Society for Health Policy SGGP, Zurich 2004, ISBN 3-85707-803-0 .
  • InEK GmbH (ed.): G-DRG case flat rate catalog 2008. ISBN 978-3-940001-11-5 .
  • InEK GmbH (Ed.): German Coding Guidelines Version 2008. ISBN 978-3-940001-12-2 .
  • Ludwig Kuntz, Stefan Scholtes, Antonio Vera: DRG Cost Weight Volatility and Hospital Performance. In: OR Spectrum. Volume 30, No. 2, 2008, pp. 331–354.
  • Thomas Müller: DRG basic knowledge for doctors and coders. A quick guide. Medizificon Verlag , Mannheim 2007, ISBN 978-3-9810027-5-1 .
  • Boris Rapp: practical knowledge DRG - optimization of structures and processes. Kohlhammer-Verlag, 2007, ISBN 978-3-17-019396-3 .

Individual evidence

  1. ↑ a b A. Vera, M. Lüngen: The reform of hospital financing in Germany and the effects on hospital management. In: WiSt - Das Wirtschaftsstudium. Volume 31, No. 11, 2002, p. 638 ff.
  2. ↑ JD Thompson, RB Fetter, CD Mross: Case mix and resource use. In: Inquiry. 12 (4), Dec 1975, pp. 300-312.
  3. ↑ A. Vera: The "industrialization" of the hospital system through DRG case flat rates - an interdisciplinary analysis. In: Healthcare. Volume 71, No. 3, 2009, p. 161 f. and p. e10 ff.
  4. ^ Robert B. Fetter: DRGs - Their Design and Development. Health Administration Press, Ann Arbor, Michigan 1991, ISBN 0-910701-60-1 .
  5. ^ William C. Hsiao, Harvey M. Sapolsky, Daniel L. Dunn, Sanford L. Weiner: Lessons of the New Jersey DRG payment system. 1986, on: content.healthaffairs.org (PDF; 210 kB)
  6. ↑ Antonio Vera: The “industrialization” of the hospital system through DRG case flat rates - an interdisciplinary analysis . In: Healthcare . tape 71 , no. 3 . Thieme Verlag, February 16, 2009, ISSN  0941-3790 , p. e10-e17 , doi : 10.1055 / s-0028-1102941 .
  7. ↑ Falk Osterloh: Hospitals - Journey into the Unknown In: Deutsches Ärzteblatt, Issue 3, January 17, 2020, pp. B 51 - B 55, here: B 54: Criticism of the DRG system ( online ).
  8. ↑ SwissDRG AG

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