Flat rate per case and special fee
The flat rate per case is a form of reimbursement for services in the health system . In contrast to period based schemes (such as same day care rates ) or a payment of individual services ( fee for service ) is performed at flat rates, remuneration of medical services per treatment case .
The process is used internationally in many countries. The aim of the procedure is to limit the overall costs in the healthcare system.
Since 2004, due to a change in the legal basis, the flat rates per case have been systematized according to the German Diagnosis Related Groups (G-DRG) classification system, which in turn refers to the ICD-10-GM classification . The legal basis is SGB V.
In Germany, a flat-rate agreement applies in each case (FPV 2014). It is concluded jointly and uniformly between the GKV-Spitzenverband, Berlin and the Association of Private Health Insurance, Cologne, as well as the German Hospital Society. This includes a flat rate catalog.
The Federal Care Rate Ordinance was introduced in 1954. The dual financing system, which was legally anchored in the Hospital Financing Act (KHG) in 1972, improved the hospitals' economic security through cost-covering care rates for hospital services provided. The Federal Care Rate Ordinance of 1974 also contributed to this. The amended Federal Care Rate Ordinance, which came into force in 1986, created more transparency with regard to costs and performance-based remuneration systems.
The aim of the Health Structure Act (GSG) passed in 1992 was to replace the cost recovery principle that had been in force since 1972 with a performance-based remuneration system. With the abolition of the self-cost coverage principle, the connection of the hospital budget was linked to the increase in the income of the health insurers, and special fees and flat-rate fees were introduced instead of the same daily care rate.
From 1996 to 2004, flat-rate case fees were used in Germany to reimburse individually defined medical service complexes - for example inguinal , biliary , appendix operations - in hospitals . A flat rate per case was defined using the diagnosis encoded according to ICD-10-GM and the diagnosis according to the International Classification of Procedures in Medicine ( ICPM , or, in Germany, operation code according to Section 301 SGB V (OPS-301) , now replaced by OPS-2008 ) encrypted performance (procedure). If the main diagnosis and procedure corresponded to the case flat rate definition, this was billed instead of the nursing care rates.
In addition to the flat-rate case fees, there were special fees , some of which were defined for the same services, but were only invoiced if the corresponding procedure was encrypted, but the diagnosis required for the flat-rate case did not correspond to the main diagnosis . Additional special fees were provided for certain, in some cases particularly complex, operations - for example major lung or abdominal operations. The special fees were billed alongside nursing care rates. With the introduction of the DRG system, optional from 2003 and mandatory from 2004, the flat-rate billing is expanded to include almost all outpatient and partially or fully inpatient hospital treatments with the exception of psychiatry .
The calculation is based on a case flat rate system that divides a case into diagnosis-related case groups. The case group is assigned certain monetary values for standard cases ( base case value ). To calculate the specific flat rate per case, additional criteria are also used, such as the main diagnosis, secondary diagnosis, length of stay , duration of treatment, age and gender of the patient. The system used in Germany is G-DRG, in Switzerland SwissDRG is used.
Since the calculation of the flat rate per case can be very complicated, a computer program (so-called grouper software ) is usually used.
Criticism of the system of flat rates per case
Strict demarcation from case management
Except in the common word component `` case '', the case flat rates have nothing in common with case management . The flat-rate case fees do not allow any intervention in the current case, but only serve the administration retrospectively. A process cost recording is mostly completely unknown, so there is no real-time transparency of the actual costs in the individual case.
Lack of cost transparency
By reducing the billing to case flat rates (DRG) in Major Diagnostic Categories (MDC), the timely recording of the process costs related to the case to justify an authentic process cost calculation in the German health care system is usually completely neglected. In other countries too, for example, the original intention with the definition of DRGs as a control instrument for the economic management of hospitals has been lost.
In almost all publicly owned German hospitals, the process costs are determined from the accumulated ward costs. Therefore, the direct indicator of process quality in the monitoring of the individual case is missing. An intervention in the process management with the direct goal of optimal control in favor of the service provider and the cost bearer is therefore largely left to manual research.
Falsification of the concept by Fetter, Thompson from 1969
The original concept of the inventors of the flat rate per case, Robert B. Fetter and John Devereaux Thompson, is not represented by the system that has existed since 2003. Apart from an accounting system, nothing remains of the idea of controlling decisions in practice. The past four decades have done nothing to further develop the proposed system. Instead, it is largely crippled with the long adjustment cycles now defined.
This criticism applies to Germany as well as to the German-speaking neighboring countries Austria and Switzerland as well as to the country of the original, Australia.
- The doctors' appeal: Against the dictates of the economy in our hospitals , Stern, September 7, 2019
- rate case agreement (PDF; 52 kB) (FPV 2014)
- rate catalog (PDF; 873 kB) G-DRG version 2014
- Robert B. Fetter: DRGs - Their Design and Development. Health Administration Press, Ann Arbor, Michigan 1991, ISBN 0-910701-60-1
- A Decision Model for the Design and Operation of a Progressive Patient Care Hospital, Medical Care, November 1969, Vol. VII, No. 8, pp. 450-462.