Fallpauschalenentwicklung in der rekonstruktiven Mammachirurgie

Abstract

Diagnosis-Related Groups (DRG) were introduced in Germany in 2004 as a medico-economic classification system. In this analysis, we looked at reconstructive surgery after breast cancer, focusing on changes of the fee-per-case system in the last 6 years. Immediate, delayed, pedicle and free flaps as well as alloplastic reconstructive methods were analysed using data from German reference hospitals. We analysed the length of stay, reimbursements, costs and profits. The biggest profit margin was found in free perforator flaps. These were up to 3 times higher than in alloplastic reconstruction and pedicle flaps. Due to the fact that the underlying costs for the calculation of reimbursement are always retrospective, we accounted for the rate of price increase. In spite of increasing mean profits, foregone profits of up to €574 per case due to inflation were not taken into consideration. Contrary to actual guidelines, neither the immediate reconstruction of the breast by autologous tissue, nor the bilateral reconstruction is taken into account economically. Although a more differentiated reimbursement of breast reconstruction by DRG has taken place in the last years, the subject still remains a classical example for insufficient mapping of new medical standards in our DRG system. As the choice of surgical therapy is increasingly influenced by free market mechanisms, the risk for economic selection in contradiction to clinical recommendations becomes a real problem. Even 9 years after its introduction, the German DRG system is far from being a learning or quick adapting system.

Reimbursement for reconstruction by tissue transfer–a European comparison

“…For pedicled flaps, the mean value for reimburses of the five countries was 5933€ and in contrary 8517€ for free tissue transfer. We found no different procedure codes to distinguish free myocutaneous flaps from perforator flaps such as for reconstructive breast surgery in some countries [ 14 ]. The authors think this would also make sense for tissue transfer to other body regions than the breast, however, no information about potential cost differences is available so far that could justify such a distinction.…”

Relevance of Health Economics in Breast Cancer Treatment: Integration of Economics in the Management of Breast Cancer at the Clinic Level

“…This was also supported by a recent comparison of breast cancer DRGs in 10 European countries showing that flat-rate reimbursement can vary between different countries as well as payment over time, concluding that policy makers in 7 countries should re-evaluate their DRG systems regarding algorithms and classification for appropriateness [55]. Repeated analyses of DRGs in breast cancer treatment by clinical physicians have shown that despite a 10-year learning process German DRGs are still not cost-covering for the breast cancer care provided [33,56,57]. …”

Critical Evaluations of the French Health Care Accounting Indicators: The Use of Drgs

“…In the US, early assessments of DRGs' impact on quality appears negative. DRGs have the potential to lessen the quality of care because decisions are based on economic factors rather than clinical recommendations (Lotter et al, 2012;Cheng et al, 2009;Frei, 2005). DRG pitfalls include a shorter stay in the acute sector (the elderly are discharged faster and quicker in the DRG Medicare program) (Qian et al, 2011), early admission into rehabilitative care (von Eiff et al, 201;Lenk et al, 2005) or being discharged to the community rather than to a medical institution (Dobrez et al, 2010), which can lead to higher readmissions rates (Qian et al 2011) .…”