[Possibilities and limitations for the representation of ENT medicine in the G-DRG reimbursement system. Results of the DRG evaluation project]

[ENT medicine and head and neck surgery in the G-DRG system 2008]

BACKGROUND

Further developments in the German DRG system have been incorporated into the 2008 version. For ENT medicine and head and neck surgery significant changes concerning coding of diagnoses, medical procedures and concerning the DRG-structure were made.

METHODS

Analysis of relevant diagnoses, medical procedures and G-DRGs in the versions 2007 and 2008 based on the publications of the German DRG institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI).

RESULTS

Changes for 2008 focussed on the development of DRG structure, DRG validation and codes for medical procedures. The outcome of these changes for German hospitals may vary depending on the range of activities.

CONCLUSION

The G-DRG system has gained in complexity again. High demands are made on correct and complete coding of complex ENT and head and neck surgery cases. Quality of case allocation within the G-DRG system has been improved. For standard cases quality of case allocation is adequate. Nevertheless, further adjustments of the G-DRG system especially for cases with complex neck surgery are necessary.

[Cost calculations for treating penetrating eye injuries within the DRG C01Z at a university eye hospital]

BACKGROUND

Since 2004, inpatient health care for penetrating eye injuries in Germany had been paid according to the calculated DRG C01Z. Because the extent of treatment mainly derives from the extent of eye damage, this DRG economically summarises very heterogeneous cases. It was the aim to check the cost recovery for the surgical treatment of penetrating eye injuries at a university eye hospital.

MATERIAL AND METHODS

Performance data for the DRG C01Z were collected for the years 2005 and 2006 using the E1 sheets according to section sign21 KHEntG. Costs for single operations were calculated from fixed and variable costs for the operating theatre and the ward, including costs for personnel and supplies.

RESULTS

In the 2-year period, out of 4,721 inpatient procedures, 180 perforating eye injuries were surgically treated. In 80 cases, a pure corneal/scleral suture (plus cataract surgery, n=10; mean operating time 67.81 min) was performed. In the other 100 cases, a pars plana vitrectomy (ppV) with adjuvant measures (mean operating time 124.69 min) was needed. Each operation had fixed surgical costs of EUR 130.60; variable costs, including personnel and supplies, varied between EUR 570 for corneal/scleral suture (+/-EUR 250 for combined cataract surgery (n=10) and EUR 1230 (mean) for a ppV. Cost-effective additional adjuncts such as cerclage, perfluorocarbon, gas, silicone oil, or cataract surgery led to extra costs of between EUR 51 and EUR 250 per adjunct (mean EUR 182). At least two of these adjuncts were used in 50% of ppVs, and at least one was used in 90% of ppVs. Hospitalisation costs were about EUR 2184 (EUR 273 per day), with a mean stay of 8 days. The overall costs of an operation for penetrating eye injuries differed significantly in terms of the procedure (corneal/scleral suture: EUR 2662, mean length of stay 7.06 days; ppV: EUR 3712, mean length of stay 8.62 days). Additional costs for multiple surgeries, as occurred in 11.1% of all cases, were not compensated by the DRG system.

CONCLUSION

In consideration of a relative DRG weight of 1,177 and a base rate of EUR 2723.79 in Bavaria for 2005 and 2006, perforating eye injuries were compensated within the C01Z DRG at EUR 3205,96. Thus, for ppVs no costs are recovered, whereas "pure suture" procedures are overweighted. Due to this inhomogeneity, a split in the C01Z DRG is necessary.

[Cost recovery for the treatment of retinal and vitreal diseases by pars plana vitrectomy under the German DRG system]

BACKGROUND

Since 2004 inpatient health care in Germany is paid according to calculated DRGs. Only a few university hospitals participated in distinct cost calculations of clinical treatment. It was the aim of this study to check the cost recovery at a University Eye Hospital for the surgical treatment of retinal and vitreal diseases by pars plana vitrectomy (ppV), which are included in DRGs C03Z and C17Z.

MATERIAL AND METHODS

The performance data for both DRGs were collected for the years 2005 and 2006 using the E1 sheets according to section 21 KHEntG. The mean duration of all procedures was collected by data from the internal controlling. Costs for single operations were calculated from fixed and variable costs for the operation theatre and the ward including costs for personnel and material.

RESULTS

In the 2-year period of 4,721 inpatient procedures 1,307 ppVs were performed. Each ppV had fixed surgical costs of 130.60 EUR; personnel costs varied between 575 EUR (C03Z; including cataract surgery; mean OP duration: 85 min) and 510 EUR (C17Z; no cataract surgery; mean OP duration: 73 min) at a proportion between general anaesthesia and local anaesthesia of 80/20. For a pure ppV material costs were 255 EUR. Additional adjuncts such as an encircling band, perfluorcarbon, ICG, tPA, gas and silicon oil or cataract surgery led to extra costs between 51 EUR and 250 EUR per adjunct und were used in 56% (C03Z) and 74.5% (C17Z) of all procedures. Costs for hospitalisation were about 1765 EUR at a mean residence time of 6.5 days. Thus, the overall costs of a pure basic ppV amounted to 2975 EUR (C03Z) and 2661 EUR (C17Z). In consideration of the current relative DRG weights of 1.08 and 0.957 and a current base rate of 2787.19 EUR in Bavaria, cost recovery is only given for basic ppV but not for complex ppVs having higher material and personnel costs. Additionally, the costs for multiple surgeries as occur in 5.9% of cases are not compensated by the DRG system.

CONCLUSION

The reimbursement for inpatient ppVs in a University environment is not covered for complex procedures requiring more cost-effective material and personnel time. To consider an adequate cost recovery for these procedures a DRG split for both DRGs (C03Z and C17Z) in basic ppVs and complex ppVs is required. We recommend this proposal for the InEK.

[Case allocation of extensive operations on head and neck within the German DRG system 2004-2007: what is the net result of the continued developments in case allocation?]

BACKGROUND

When the German DRG system was implemented there was some doubt about whether patients with extensive head and neck surgery would be properly accounted for. Significant efforts have therefore been invested in analysis and case allocation of those in this group. The object of this study was to investigate whether the changes within the German DRG system have led to improved case allocation.

METHODS

Cost data received from 25 ENT departments on 518 prospective documented cases of extensive head and neck surgery were compared with data from the German institute dealing with remuneration in hospitals (InEK). Statistical measures used by InEK were used to analyse the quality of the overall system and the homogeneity of the individual case groups.

RESULTS

The reduction of variance of inlier costs improved by about 107.3% from the 2004 version to the 2007 version of the German DRG system. The average coefficient of cost homogeneity rose by about 9.7% in the same period. Case mix index and DRG revenues were redistributed from less extensive to the more complex operations. Hospitals with large numbers of extensive operations and university hospitals will gain most benefit from this development.

CONCLUSION

Appropriate case allocation of extensive operations on the head and neck has been improved by the continued development of the German DRG system culminating in the 2007 version. Further adjustments will be needed in the future.

[The German DRG system and its effect on imaging quality in ENT, and head and neck surgery]

BACKGROUND

The new G-DRG system for 2006 was published in September 2005. This article presents, analyses, and comments essential changes in the G-DRG system for 2006 and their consequences for ENT-Medicine.

RESULTS

The complexity of the G-DRG system has increased significantly. In 2006, the case allocation will be more differentiated for common surgical procedures on the middle ear, nose, paranasal sinuses, salivary glands, and for head and neck cancer. Furthermore, the patient's age and the clinical and complexity level (PCCL) will be of increased relevance in selected case constellations. However, diagnostic endoscopies with rigid instruments will still not be regarded as OR procedures.

CONCLUSION

Essential adjustments proposed by the German Association for ENT Medicine (DGHNOKHC) and the ENT Medical Professional Association (HNO-Berufsverband) have been made, and the quality of case allocation of ENT-patients within the G-DRG system improved. Nevertheless, further adjustments to the G-DRG system are necessary.

[ENT and head and neck surgery in the German DRG system 2007]

BACKGROUND

The German DRG system has been further developed into version 2007. For ENT and head and neck surgery, significant changes in the coding of diagnoses and medical operations as well as in the the DRG structure have been made.

RESULTS

New ICD codes for sleep apnoea and acquired tracheal stenosis have been implemented. Surgery on the acoustic meatus, removal of auricle hyaline cartilage for transplantation (e. g. rhinosurgery) and tonsillotomy have been coded in the 2007 version. In addition, the DRG structure has been improved. Case allocation of more than one significant operation has been established.

CONCLUSION

The G-DRG system has gained in complexity. High demands are made on the coding of complex cases, whereas standard cases require mostly only one specific diagnosis and one specific OPS code. The quality of case allocation for ENT patients within the G-DRG system has been improved. Nevertheless, further adjustments of the G-DRG system are necessary.