[Orthopedic and trauma surgery in the German DRG system 2008]

Original Article: The impacts of DRG payment system on financial balance of multiple trauma: Experiences of three trauma centers in Taiwan

INTRODUCTION

There are concerns regarding the adequacy of applying the diagnosis-related groups (DRG) payment system for multiple traumas (i.e., major diagnostic category 24, MDC-24) patients in Taiwan. Therefore, this study used a multi-center dataset to assess the influence of the DRG payment system on the cost and outcome of multiple trauma care.

MATERIALS AND METHODS

We collected data of all multiple trauma patients from the Trauma Registry of three hospitals from 2014 - 2017. Next, we selected patients who met the criteria of MDC-24 and calculated the corresponding DRG payment. Subsequently, we combined the clinical care information with health insurance information to analyze the problems of applying the DRG payment system to multiple trauma care.

RESULTS

Overall, of 465 cases, 367 met the criteria of MDC-24, and the mean injury severity score (ISS) was high (average 20.1). The total deficit of the polytrauma DRG cases amounted to 131,445 USD, and the average deficit in each case was 397 USD. In the multivariable analysis, higher revised trauma score and specific lower abbreviated Injury Scale (AIS) scores in certain body regions resulted in profits, while increased length of stay in intensive care units, longer operative time, and higher AIS score in the thorax were significantly correlated with deficits in medical costs.

CONCLUSION

Our study revealed that the current DRG payment system results in financial losses for hospitals. Further, the payment grouping of MDC-24 should consider adding more disease severity factors to reduce the financial constraints faced by trauma centers.

[The economic challenges of polytrauma care]

Following the introduction of DRGs ("diagnosis-related groups") in Germany, reimbursements changed from a per diem rate to a flat charge per patient. DRGs are defined by the German Institute for the Hospital Remuneration System (InEK, Institut für das Entgeltsystem im Krankenhaus) along with the respective reimbursement. The revenues are set according to the diagnoses and procedures. In complex cases like serious injury this applies for the average diagnoses and procedures. As a result, several groups reported costs of polytrauma care as high as 70,000 euro with losses as high as 20,000 euro. In the USA, a similar constellation has lead to the closure of trauma centers. The main reasons for the financial deficit are heterogeneity of polytrauma patients and contingency costs. Both are difficult to transfer to a case-based compensation system. Since the German DRG system was designed to learn during introduction, there were adjustments to reimbursements for polytrauma care in the initial phase. However, in recent years, no further improvements in the care of severely injured patients have been seen. The deficit per seriously injured patient currently runs at approx. 5000 euro. A renewed joint effort is required in order to avoid an economy-related reduction in quality of care.

[Physicians in traumatology. Critically endangered? Results of an inquiry]

INTRODUCTION

The aim of this investigation was to describe the current situation and atmosphere among residents and consultants in traumatology, using the results of a questionnaire. Wishes and needs concerning training programs in traumatology were addressed.

METHODS

A questionnaire consisting of 25 items was distributed among members of the German Society of Traumatology (DGU) to document basic data concerning the state of residency and physicians' current workload. The participants were also asked about their personal interests and aims within traumatology. Finally, questions concerning educational programs, compensation, and work-life balance were addressed. The results were analysed descriptively.

RESULTS

The final analysis included 549 questionnaires. The mean age of the participants was 36 years (SD +/-7.5). Sixty percent (329) were residents, and 16% (88) served as consultants. The mean workload per week was 61 h (SD +/-10.8 h), and participants were on call seven times (SD +/-5.6) a month. The work-life balance was rated a mean of only 5 ("mediocre"). The majority of participants rejected working longer in order to reduce the duration of their educational program. On the other hand, most of the participants would also reject a reduction in working time accompanied by a reduced salary. Nevertheless, 78% (428) of the participants would, in retrospect, choose the same profession, and 85% (466) would even choose the same specialty.

DISCUSSION

The study reports on the atmosphere among residents and consultants in traumatology. Despite European regulations, the individual workload is exceptionally high. It is a clear task of hospital administrators to increase the attractiveness of hospital jobs in order to ensure qualified personnel in the future.

[Orthopedic and trauma surgery in the German-DRG-System 2009]

BACKGROUND

The German DRG-System was advanced into version 2009. For orthopedic and trauma 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 2008 and 2009 based on the publications of the German DRG-institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI).

RESULTS

Changes for 2009 focussed on the development of DRG-structure, DRG-validation and codes for medical procedures to be used for very complex cases. The outcome of these changes for German hospitals may vary depending in the range of activities.

CONCLUSION

G-DRG-System gained complexity again. High demands are made on correct and complete coding of complex orthopedic and trauma surgery cases. Quality of case-allocation within the G-DRG-System was improved. Nevertheless, further adjustments of the G-DRG-System especially for cases with severe injuries are necessary.

[Operative treatment of instable osteoporotic spine fractures. A good guide in coding of diagnosis]

The combination of kyphoplasty and fixateur interne is an essential therapy with osteoporotic unstable fractures. Material costs of 5500 Euro are not sufficiently covered by returns through DRG I09. Thus operations are often performed in 2 stages, an initial one and a second 30 days later. This means more strain for the patient and partly also loss of correction. Therefore in 2008 we requested the InEK that codes for one-and two-segmental implantation of material in a vertebrae with preceding restoration of vertebral height (5-839.a0 and 5-839.a1) combined with a percutaneous dorsal operation with a screw-rod system in the future would be represented by I19B in G-DRG system with returns of 11,110,40 Euro. Prerequirement is coding of kyphoplastiy as main procedure and percutaneous implantation of a fixateur with procedure 5-835.5. Some procedures in orthopedic surgery implying technical improvements and rising implant costs are not sufficiently rewarded. Thus is make sense to inform InEK by corresponding proposals.