Length of stay
The term length of stay (or length of stay) is used in healthcare . It indicates the number of days that a patient on average in one hospital inpatientis treated. In addition to the number of hospital cases, the length of stay is of decisive importance for determining the bed requirement. The average length of stay of a patient in hospital is influenced, among other things, by individual factors such as age, gender, constitution, type and severity of illness, marital status, shared apartment, type of health insurance; medical factors such as level of development of medicine, discipline, qualifications of doctors and nurses; Hospital-specific factors such as the availability and use of beds, discharge practice, type and scope of medical-technical equipment, size and age of the hospital, type of hospital operator. A hospital itself can influence the length of stay to a limited extent.
The definition of the length of stay in accordance with Section 1 (7) of the Ordinance on the Flat-Rate System for Hospitals (KFPV) is: The number of days of occupancy is decisive. Occupancy days are the day of admission and each additional day of the hospital stay without the day of transfer or discharge ...; if a patient is admitted and transferred or discharged on the same day, this day is considered to be the admission day. The presence at midnight is counted. Example: Admission Monday, discharge Friday, length of stay 4 days. The length of stay can be given as an average value for entire countries, for specialist departments and for certain diagnoses.
background
In Germany, the length of stay in hospitals is of considerable financial importance. The billing according to daily rates for longer hospital stays, which was customary before 2004, led to additional revenues. In the course of the health reform , efforts were made to prevent such medically unnecessary inpatient treatments and to change them through the law that came into force in March 2002 to introduce the diagnosis-oriented accounting system based on flat-rate per case for hospital services .
The case-based flat-rate reimbursement means that the hospitals can bill the cost bearers a fixed amount for certain diagnoses (see ICD-10 ) and procedures (see OPS ). This was introduced with the GMG for health insurance companies . The introduction of flat rates per case based on diagnoses, however, harbors the risk that clinicians might feel pressured to make diagnoses more often or to carry out procedures and operations more frequently for which the employer, e.g. a privately owned hospital, receives a higher flat rate per case from the insurance provider and which may not be medically necessary or useful. The case flat rates ( DRGs ), which have been binding since January 1, 2004, replace the daily rates previously used for billing. This also introduced the term length of stay. In contrast to the previous form of billing, the longer a patient stays in the hospital, the more the costs of a clinic increase with a flat rate billing with the same proceeds. Therefore, there is an economic incentive for the hospitals to discharge patients home or for further outpatient treatment as early as possible.
The reimbursed length of stay therefore depends on the case group into which a patient was classified. Determining factors for the case group are the main diagnosis made, possible secondary diagnoses, the procedures carried out and other case-relevant criteria.
In Germany, the average length of stay in 2003 was 8.9 days, while the EU average was 6.1 days. A further reduction in the length of stay in Germany cannot be ruled out.
Limit length of stay
A distinction is made between an upper and lower limit length of stay (GVD):
Upper limit length of stay (according to the case flat rate catalog)
The upper limit of length of stay defines the length of stay in the hospital from which a day-based surcharge is paid. For each individual DRG, the first day with surcharge and a valuation ratio per surcharge day are shown in the case flat rate catalog in accordance with the valid case flat rate agreement (FPV). (Example for 2016 DRG 901C OGVD = 33 and valuation ratio per day 0.093) for the 1st day with surcharge and for each additional day of occupancy of the hospital stay, this valuation ratio is then added (in the 901C example, with 42 days of stay, 10 surcharge days and thus 10 * 0.093, i.e. surcharge of 0.930). Whether these cover the corresponding additional costs depends on the individual case.
The surcharge amount is then determined by multiplying the additional valuation ratio for this case by the respective country's base case value.
Lower length of stay
If the length of stay of the patient is not longer than the lower limit of the length of stay , a discount will be calculated from the flat rate per case. In the case flat rate catalog, the lower limit of length of stay is specified as the first day with a discount and a valuation ratio for each discount day.
Example: DRG 2016 B70E for strokes
1st day with discount 2nd day
Evaluation ratio per day 0.501
This means with a residence time (VWD) of 1 day, 1.002 is deducted from the relative weight (RG): 1.515 - 1.002 = 0.510
For VWD of 2 days 0.501: 1.515 - 0.501 = 1.014
The full RG is only calculated from the VWD of 3 days = 1.515
There are DRGs where the discount is only estimated and some where the costs for the short stayers were calculated separately. This takes into account the lower effort for the patient, more or less precisely.
The revenue for is calculated to the cost unit by multiplying the calculated effective weight with the respective state base rate. This means that the discount for a national base rate of, for example, 3200 euros in the above example is for one day
VWD 1 T discount 3206.40 hospital receives 1632.00 euros.
VWD 2 T discount 1603.20 hospital receives 3235.20 euros
VWD 3 T discount 0 hospital receives 4848.00 euros
This applies up to 19 days VWD because the upper limit of the length of stay for the B70E is set at 20 T, there is an additional surcharge of 0.111 RG for every day from VWD 20, which means 355.20 euros
.
International overview of the length of stay
In 2007 the OECD published statistics on the average length of stay in acute care. In Japan it is 19.8 days, in Germany 8.6 and in Switzerland 8.5 days. Other countries: Czech Republic 8, Slovak Republic and Luxembourg 7.3, Portugal 7.1, Netherlands 6.8, Ireland 6.6, Poland 6.5, Hungary 6.3, United Kingdom 6.1, Austria 5.9 , USA 5.6, Iceland and France 5.4, Norway 5.2, Finland 4.8, Sweden 4.6, Mexico 4 and Denmark 3.5. The average of these countries is 6.8 days. No data were available from the following OECD countries: Australia, Belgium, Greece, Italy, Canada, South Korea, New Zealand, Spain and Turkey.
Criticism of the shortened length of stay
An early discharge of patients from the hospital for economic reasons is described by critics as a "bloody discharge". In addition to the risks for the patient, early discharges also involve cost risks for the payers, e.g. For example, if the illness increasingly requires outpatient treatment, home nursing or even a renewed inpatient hospital stay (“ revolving door effect ”).
Doctors in private practice are criticized for having to bear the economic risk of being discharged, since the outpatient treatments become more expensive and time-consuming as the healing process is not completed, without being fully billed to the insurance providers.
Avoidance strategies
In order to avoid “bloody discharges”, the length of stay was regulated in the billing procedure with the hospitals. Particularly short hospital stays result in deductions or a specially calculated case flat rate, especially long stays surcharges on the case flat rate. In addition, there are deadlines after discharge from the hospital, which exclude the billing of a new flat rate case in the event of a new inpatient admission. However, this only applies if certain criteria of the flat-rate agreement (FPV) are met. In Section 17 b of the Hospital Financing Act, the legislature stipulated that accompanying research must be submitted by the end of 2005. The contract for this was placed in May 2008 through a tender in the Official Journal of the European Union.