Reimbursement of care for severe trauma under SwissDRG

Moos, Rudolf; Sprengel, Kai; Jensen, Kai Oliver; Jentzsch, Thorsten; Simmen, Hans‐Peter; Seifert, Burkhardt; Ciritsis, Bernhard; Neuhaus, Valentin; Volbracht, Jörk; Mehra, Tarun

doi:10.4414/smw.2016.14334

Cited by 6 publications

(13 citation statements)

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“…Among severely injured or “polytraumatized” patients, the impact on society is by far more than that in patients with isolated trauma. The polytrauma population needs to be accurately identified to allow appropriate reimbursement and benchmarking of trauma centers [ 2 ]. Coding represents the most important tool to compare the individual injury severity on defining the severity of injuries in general and in identifying a patient with polytrauma.…”

Section: Introductionmentioning

confidence: 99%

Assessment of polytraumatized patients according to the Berlin Definition: Does the addition of physiological data really improve interobserver reliability?

Pothmann

Jensen

et al. 2018

PLoS ONE

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BackgroundSeveral new definitions for categorizing the severely injured as the Berlin Definition have been developed. Here, severely injured patients are selected by additive physiological parameters and by the general Abbreviated Injury Scale (AIS)-based assessment. However, all definitions should conform to an AIS severity coding applied by an expert. We examined the dependence of individual coding on defining injury severity in general and in identifying polytrauma according to several definitions. A precise definition of polytrauma is important for quality management.MethodsWe investigated the interobserver reliability (IR) between several polytrauma definitions for identifying polytrauma using several cut-off levels (ISS ≥16, ≥18, ≥20, ≥25 points, and the Berlin Definition). One hundred and eighty-seven patients were included for analyzing IR of the polytrauma definitions. IR for polytrauma definitions was assessed by Cohen’s kappa.ResultsIR for identifying polytrauma according to the relevant definitions showed moderate agreement (<0.60) in the ISS cutoff categories (ISS ≥16, ≥18, and ≥20 points), while ISS ≥25 points just reached substantial agreement (0.62) and the Berlin Definition demonstrated a correlation of 0.77 which is nearly perfect agreement (>0.80).ConclusionCompared with the ISS-based definitions of polytrauma, the Berlin Definition proved less dependent on the individual rater. This underlines the need to redefine the selection of severely injured patients. Using the Berlin Definition for identifying polytrauma could improve the comparability of patient data across studies, in trauma center benchmarking, and in quality assurance.

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Section: Introductionmentioning

confidence: 99%

Assessment of polytraumatized patients according to the Berlin Definition: Does the addition of physiological data really improve interobserver reliability?

Pothmann

Jensen

et al. 2018

PLoS ONE

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“…B. ISS >15) [6,17,[27][28][29][30]32], die SR-Versorgung [13], spezifische Verletzungsmuster wie Verbrennung [26] und Schädel-Hirn-Trauma (SHT) [34] oder das Trauma allgemein [9,23,31].…”

Section: Hintergrund Und Fragestellungunclassified

“…Der mittlere Case-Mix-Index betrug 1,93 (±2,26), was einem gesamten Case-Mix von 990 Punkten entsprach, wobei ein Case-Mix-Punkt im Untersuchungszeitraum CHF 9800,-ausmachte (regelhaft CHF 9700 für obligatorisch Kranken- Hingegen beschrieben die untersuchten Variablen zusammen 24 % Varianz des Deckungsgrades (. [1,5,7,21,22,27,30], wird die initiale Schwerverletztenbehandlung in allen internationalen Angaben, auch unter Anwendung der DRG-Entgelte, als defizitär beschrieben [26]. Erstaunlicherweise scheint die aktuelle Swiss-DRG-Entgeltung die Aufwände eines Schweizer Traumazentrums noch weniger zu decken, als dies für Deutschland der Fall ist [12,27] und sich, im Gegensatz zu Deutschland, über die letzten Jahre auch nicht verbessert zu haben [14,27].…”

Section: Conclusion From Aunclassified

“…Bzgl. DRG-Erlösen gilt es, die länderspezifischen Versionen zu berücksichtigen, allerdings erlauben die Angaben gemäß schweizweit angewandtem REKOLE©-Verfahren zumindest zwischen Schweizer Spitälern vergleichbare Untersuchungen, welche allerdings bisher nicht durchgeführt wurden [27,34]. Die in diesem Artikel enthaltenen Bilder und sonstiges Drittmaterial unterliegen ebenfalls der genannten Creative Commons Lizenz, sofern sich aus der Abbildungslegende nichts anderes ergibt.…”

Section: Limitationenunclassified

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Schockraum- und Schwerverletztenversorgung als „Verlustgeschäft“

Groß

Amsler

2020

Unfallchirurg

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Zusammenfassung Hintergrund Es galt herauszufinden, wie kostendeckend die Versorgung potenziell Schwerverletzter in einem Schweizer Traumazentrum ist, und inwieweit Spitalgewinne bzw. -verluste mit patientenbezogenen Unfall‑, Behandlungs- oder Outcome-Daten korrelieren. Methodik Analyse aller 2018 im Schockraum (SR) bzw. mit Verletzungsschwere New Injury Severity Score (NISS) ≥8 notfallmäßig stationär behandelter Patienten eines Schwerverletztenzentrums der Schweiz (uni- und multivariate Analyse; p < 0,05). Ergebnisse Für das Studienkollektiv (n = 513; Ø NISS = 18) resultierte gemäß Spitalkostenträgerrechnung ein Defizit von 1,8 Mio. CHF. Bei einem Gesamtdeckungsgrad von 86 % waren 66 % aller Fälle defizitär (71 % der Allgemein- vs. 42 % der Zusatzversicherten; p < 0,001). Im Mittel betrug das Defizit 3493.- pro Patient (allg. Versicherte, Verlust 4545.-, Zusatzversicherte, Gewinn 1318.-; p < 0,001). Auch „in“- und „underlier“ waren in 63 % defizitär. SR-Fälle machten häufiger Verlust als Nicht-SR-Fälle (73 vs. 58 %; p = 0,002) wie auch Traumatologie- vs. Neurochirurgiefälle (72 vs. 55 %; p < 0,001). In der multivariaten Analyse ließen sich 43 % der Varianz erhaltener Erlöse mit den untersuchten Variablen erklären. Hingegen war der ermittelte Deckungsgrad nur zu 11 % (korr. R2) durch die Variablen SR, chirurgisches Fachgebiet, Intensivaufenthalt, Thoraxverletzungsstärke und Spitalletalität zu beschreiben. Case-Mix-Index gemäß aktuellen Diagnosis Related Groups (DRG) und Versicherungsklasse addierten weitere 13 % zu insgesamt 24 % erklärter Varianz. Diskussion Die notfallmäßige Versorgung potenziell Schwerverletzter an einem Schweizer Traumazentrum erweist sich nur in einem Drittel der Fälle als zumindest kostendeckend, dies v. a. bei Zusatzversicherten, Patienten mit einem hohen Case-Mix-Index oder einer IPS- bzw. kombinierten Polytrauma- und Schädel-Hirn-Trauma-DRG-Abrechnungsmöglichkeit.

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“…Relevant publications offer only opinions and perspectives rather than presenting research evidence on reimbursement regulations for injury-induced expenses. [ 13 – 17 ] Studies from some other countries do examine empirically the impact of social medical insurance on medical service utilization[ 18 – 20 ] and health outcomes of trauma patients,[ 18 , 21 – 24 ] and they suggest expansion of medical insurance accessibility and improved medical insurance benefits in select nations,[ 25 , 26 ] but they do not specifically address the extent to which reimbursement for injury-induced medical expenses is covered by social medical insurance schemes.…”

Section: Introductionmentioning

confidence: 99%

Reimbursement for injury-induced medical expenses in Chinese social medical insurance schemes: A systematic analysis of legislative documents

Gao

Schwebel

et al. 2018

PLoS ONE

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Social medical insurance schemes are crucial for realizing universal health coverage and health equity. The aim of this study was to investigate whether and how reimbursement for injury-induced medical expenses is addressed in Chinese legislative documents relevant to social medical insurance. We retrieved legislative documents from the China National Knowledge Infrastructure and the Lawyee databases. Four types of social medical insurance schemes were included: urban employee basic medical insurance, urban resident basic medical insurance, new rural cooperative medical system, and urban and rural resident medical insurance. Text analyses were conducted on all identified legislative documents. As a result, one national law and 1,037 local legislative documents were identified. 1,012 of the 1,038 documents provided for reimbursement. Of the 1,012 documents, 828 (82%) provided reimbursement only for injuries without a legally responsible person/party or not caused by self-harm, alcohol use, drug use, or other law violations, and 162 (16%) did not include any details concerning implementation. Furthermore, 760 (92%) of the 828 did not provide an exception clause applying to injuries when a responsible person/party could not be contacted or for situations when the injured person cannot obtain reimbursement from the responsible person/party. Thus, most Chinese legislative documents related to social medical insurance do not provide reimbursement for medical expenses from injuries having a legally responsible person/party or those caused by illegal behaviors. We argue that all injury-induced medical expenses should be covered by legislative documents related to social medical insurance in China, no matter what the cause of the injury. Further research is needed to explore the acceptability and feasibility of such policy changes.

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Reimbursement of care for severe trauma under SwissDRG

Abstract: The reimbursement for care of severely injured patients needs further improvement. Cost neutral treatment was not possible under the first three versions of SwissDRG.

Cited by 6 publications

References 1 publication

Assessment of polytraumatized patients according to the Berlin Definition: Does the addition of physiological data really improve interobserver reliability?

Assessment of polytraumatized patients according to the Berlin Definition: Does the addition of physiological data really improve interobserver reliability?

Schockraum- und Schwerverletztenversorgung als „Verlustgeschäft“

Reimbursement for injury-induced medical expenses in Chinese social medical insurance schemes: A systematic analysis of legislative documents

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