Benchmark cost model

Case-mix-analyses

With the law for modernization in compulsory health insurance companies (GKV-Modernisierungsgesetz; GMG) coming into effect in 2003, the health care policy in Germany focuses on much more differentiated remuneration of medical efforts in accordance with the patient's rate of morbidity. At the same time as morbidity-orientated risk adjustment is put into practice in 2007, standard benefit volumes and/or lump compensations based on risk classes and relative weights are defining the level of medical remuneration: Taking a glance across borders, Swiss experiences with diagnosis-related forms of remuneration is displayed.

Current development - risk classes and relative weights:

The vertices of the health care reform (4) agreed on july, 22nd 2003 are supposed to entail dramatic changes in the future job of the physician in own practice. Apart from the displacement of the system of remunerating individual performances by standard benefit volumes since 2007 (articles 3.1. and 3.2), an upgrading of special supply agreements (e.g. DMPs) and the possibility of direct contracts between cost bearers and suppliers will come into being within integrated care (article 3.8).

Accordingly, the following phrase can be found in §85a of the bill for modernization in compulsory health insurance companies (GMG 2002), resolved upon by the Bundestag on September, 29th 2003: To identify the morbidity structure according to clause 1 no. 1, the evaluation commission constitutes diagnosis-related risk classes for insurants with comparable demand in treatment based on a classificational method internationally accredited and suitable for use in statutory health insurance physician's supply; basis is the statutory health insurance physician's therapy diagnosis according to §295 paragraph 1 clause 2. The evaluation commission determines relative weights for the single risk classes; these express the deviation of the standardized treating demand per insurant in a risk class from the average treating demand per insurant of the population.

A method like that, mapping morbidity on the diagnostic data of an accredited classification method (like e.g. ICD-10) and interlinking it with medical remuneration, not only sets new standards in a more just reward of medical effort, but firstly poses a new challenge to the contractual partners in medical remuneration and requires the knowledge of a series of parameters.

To calculate the consistent baserate and thereof deducable relative weights, the correct and as far as possible detailled diagnosis is as much of crucial meaning as the comprehensive notice of the respective corresponding and adequate scope of benefits as well as the associated costs of a patient's treatment in a certain risk class.

Composition and systematics of the very risk classes, baserates, and relative weights were published on the basis of data from the TEMPO-survey® for Type-1- and Type-2-diabetics in 2003 (2,9), so that published preliminary work can be resorted to in the case of this chronic disease.

In the process, the individual mapping of each ambulantly treated patient to (a) a primary diagnosis and the definiton of (b) co-morbidities as well as their classification into (c) differentiated severity codes is going to call for a similarly systematic procedure in diagnosing in ambulant medical surgeries as can be witnessed presently in the stationary area with the introduction of the d-DRG-system.

Literature:

  1. Baur R., Hunger W., Kämpf K., Stock J.; Evaluation neuer Formen der Krankenversicherung. Synthesebericht Nr. 1/98 BSV: Beiträge zur Sozialen Sicherheit
  2. Bierwirth R. A., Kron P., Lippmann-Grob B., Funke K., Leinhos B., Grüneberg M., Huptas H., Weich K., Münscher C., Potthoff F.: Die TEMPO-Studie: Kostenanalyse in der diabetologischen Schwerpunktpraxis und Definition diabetesspezifischer Risikoprofile; Diabetes- & Stoffwechsel 12/2003, 83-94
  3. Bührer, A.: Grundlagen zur finanziellen Erfolgsbemessung in Managed Care Systemen. Schweizer Ärztezeitung (2000;81:Nr 21 1040- 1045
  4. Eckpunkte der Konsensverhandlung zur Gesundheitsreform, Homepage des Bundesministeriums für Gesundheit und soziale Sicherung
  5. http://www.bmgs.bund.de/deu/gra/themen/gesundheit/eck.cfm
  6. FoQual: Die Qualität der Gesundheitsversorgung in den Schweizer Spitälern: Analyse von sechs Indikatoren. September 2000.
  7. Huber F., Marti C., Götschi A.S., Weber A.: Managed Care in der Schweiz; Schweizer Ärztezeitschrift (2002), 83: Nr 48; 2629-2632
  8. Künzi B.: Ergebnisqualität bei chronischen Krankheiten messen und verbessern; Managed Care (2001) 5, 22-24
  9. Münscher C., Potthoff F. et al. DRG's für die ambulante Diabetologie?! Risikoprofilanalysen bei Typ-2 Diabetikern in der Diabetologischen Schwerpunktpraxis. Rotenburg/F.: AkPro (2003)
  10. Nocera S.: Rationierung- Begriffsbestimmung und Konzepte; Managed Care (2001) 6, 8-12
  11. Schenker M.: Die Qualität der Qualitätsmessung; Managed Care (2002) 2, 15-16
  12. Seitz R., König H.-H., Stillfried v.D.: Grundlagen von Managed Care in Managed Care von Arnold, Lauterbach und Preuß S.325- 340, Schattauer Verlag 1997, ISBN 3-7945-1747-4
  13. Weber A., Cottini G.: Kostenvorteile dank Risikoselektion?; Schweizer Zeitschrift Managed Care (1998) 14 - 7

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