Key words
breast cancer - surgery - outpatient setting - DRG (Diagnosis Related Groups) - EBM
(Uniform Assessment Scale)
Introduction
In Europe 2.45 million people develop cancer every year [1]. Breast cancer is the most common cancer for women in Europe. The overall cost of
oncologic disease in the EU amounts to 126 billion Euros annually, of which € 28.4
billion are for inpatient care. Breast cancer is not only a serious diagnostic and
therapeutic challenge for the various service providers but, because of its high incidence,
it has significant implications for health economics. The diagnosis, treatment, and
aftercare of patients with breast cancer require an extremely complex, time-consuming
and personnel-intensive range of services at a level not matched by almost any other
disease. In Germany, 69 550 women develop breast cancer every year. At least 5500
more women develop ductal carcinoma in situ (DCIS) [2]. On average € 13 is spent on breast cancer per person and year in the European Union.
Countries such as Lithuania and Bulgaria spend € 2 per person and year on breast cancer.
By comparison, Germany spends € 29 per person and year [1].
Since the introduction of the diagnosis-related fee-per-case system (G-DRG, German
Diagnosis-Related Groups) in Germany, in addition to medical aspects more and more
emphasis is placed on economic considerations. Reducing costs while maintaining or
even improving the quality of care is the most urgent objective. Surgical care has
been the topic of much heated debate. The Medical Services of the Health Insurance
Companies (MDK) are increasingly reviewing cases with the aim of reducing costs. The
consequences are a reduction in the length of inpatient stays and deductions to fees
when patients are in hospital for less than the minimum stipulated length of stay.
In addition, the question whether surgery for breast cancer could be done in an outpatient
setting is being increasingly debated. Interventions such as lumpectomy and sentinel
lymph node biopsy are already partly listed in the catalog of outpatient surgeries.
This in turn places a strain on the providers of services who try to ensure that their
costs are covered. Certified centers are under particular pressure as many of the
services they provide are not included in the standard scale of fees and are provided
as additional services which are not remunerated. Such non-remunerated services include
psycho-oncologic care, interdisciplinary tumor boards, further training and advanced
training, as well as higher costs for the significantly more detailed documentation
they need to provide compared to non-certified centers [3], [4]. The current data shows that certified centers deliver better process quality and
better results for patients [5], [6], [7]. The discussion whether breast cancer surgery should be done in an outpatient setting
is increasing the cost pressures on certified centers and endangering the quality
of care. According to the annual 2016 report on certified centers, 54 405 breast cancers
were treated in the 228 certified breast centers in 2015 [8]. A total of 47 495 patients with breast cancer underwent surgery. 13 801 patients
with primary breast cancer had a mastectomy and 33 695 patients had breast-conserving
surgery.
Because of the high number of cases who undergo surgery and the economic pressure,
this health economic analysis aimed to investigate inpatient procedures of patients
with primary breast cancer. The fees for procedures were determined and compared with
the fees which would be paid if the same procedure were performed in hospital in an
outpatient setting in accordance with the terms of § 115b SGB V (Volume V of the German
Social Insurance Code) [9]. The question this study aimed to answer was whether, from the point of view of
service providers, it would be possible to provide the full range of services for
breast cancer surgery patients in an outpatient setting while covering the costs incurred.
In addition, the study discusses what the expected positive and negative consequences
would be for patients if treatment shifted from in-hospital care to an outpatient
setting.
Material and Methods
Site of evaluation and patient population
Diagnostic and therapeutic steps, surgical scenarios and average length of hospital
stay were determined based on the patient population of the University Breast Center
of Franconia (UBF) of the gynecological department of Erlangen University Hospital
and the Comprehensive Cancer Center Erlangen-EMN. The UBF has been a certified center
since 2004 and meets the certification criteria of the German Cancer Society (DKG)
and the German Society for Senology (DGS). A total of 451 patients with primary breast
cancer were treated in 2015. The data of patients with primary breast cancer treated
at the UBF in 2015 who underwent breast cancer surgery for the first time, had no
relevant secondary diagnosis, and achieved R0 status after surgery were evaluated.
The respective diagnoses were coded in accordance with the German version of the ICD-10
(ICD-10-GM) and the respective OPS codes based on the International Classification
of Procedures in Medicine (ICPM) of the WHO.
DRG assignment and monetary calculation of inpatient services
The webgrouper of the DRG Research Group of the University of Münster was used to
assign the chosen scenarios to the appropriate DRGs based on their main diagnosis
code (ICD-10-GM) and the Operation and Procedure Code (OPS) in accordance with 2015
German coding guidelines [10], [11]. The average age of the patient population was used for average patient age. Reason
for admission was “referral by physician” and type of discharge was “finished regular
treatment”. The standard case was defined as “inpatient hospital treatment” in a “main
ward”. The federal base rate for 2015 which amounted to € 3311.98 was taken as the
basis when calculating the DRG fees.
Additional “day-case DRGs” were generated to construe a fee for the 1-day treatment
of every envisaged surgical scenario in analogy to the outpatient surgical scenarios.
Development of outpatient models and monetary calculation of outpatient services
An outpatient surgical procedure was defined as a gynecological surgical procedure
carried out using instruments, with the patient under a general anesthetic but without
subsequently staying overnight in hospital (hospitalization). The AOP Contract concluded
between the umbrella organizations of health insurance providers in Germany, the German
Hospital Federation (DKG) and the National Association of Statutory Health Insurance
Physicians (KBV) sets out the rules for outpatient surgeries and so-called “non-ward-based
in-hospital procedures” [9]. Costs incurred by patients who undergo surgery as outpatients (AOP patients) are
settled directly with the patientʼs health insurance company. Costs incurred by patients
who are insured by statutory health insurance companies (GKVs) are reimbursed in accordance
with rates of the currently applicable Uniform Assessment Scale (EBM). In the model
developed for this study, inpatient services received by the patient cohort were recalculated
as outpatient services (with the respective OPS code) in accordance with the 2015
EBM and the reference value for the year 2015 of 10.2718 cents [12].
To compare outpatient services as far as possible with the range of inpatient services
provided, the model also took account of the preoperative, intraoperative and postoperative
services which were directly linked to the inpatient surgical procedures. Calculations
referred to billable services in accordance with the terms of § 115b SGB V [9]. Individual services were grouped together as flat-rate fees and charges. The costs
of materials were entered in the calculation in the form of a flat-rate surcharge
of 7.0% added to the physicianʼs fee (this covered medicines, dressings and aids,
materials, single-use infusion sets, biopsy needles, etc.). The contracts do not cover
outpatient services provided to privately insured patients, services provided in cooperation
with registered physicians in private practice, the presentation of the case to a
preoperative and postoperative tumor board, or psycho-oncologic and psycho-social
counselling.
Results
Cohort
A total of 186 treated patients met the inclusion criteria. Each case was discussed
by an interdisciplinary tumor board both prior to treatment and postoperatively. Because
of the limited number of cases, the figures for galactography and MRI with contrast
agent were not representative and were therefore classified as not relevant for the
evaluation. In total, the study differentiated between 13 possible surgical scenarios
([Table 1]). The primary therapy for 147 (79%) patients was breast-conserving therapy (BCT);
58 of them only had additional sentinel lymph node biopsy (SLNB), 74 had regional
level I lymphadenectomy and 15 underwent additional level I and II axillary lymph
node dissection (ALND). Repeat resection was required in two cases and mastectomy
was required in one case to achieve R0 status. Modified radical mastectomy (MRM) was
necessary in 39 (21%) patients, of whom 8 only had SLNB, 20 had additional regional
level I lymphadenectomy, and 11 additionally underwent complete level I and II axillary
lymph node dissection. The mean patient age was 61.3 years. The mean hospital stay
was 4.85 days.
Table 1 Surgical scenarios used to treat patients.
|
Surgical scenario
|
OPS combinations
|
Description
|
|
BCT = breast-conserving therapy; SLNB = sentinel lymph node biopsy; ALND = axillary
lymph node dissection; MRM = modified radical mastectomy
|
|
Scenario 1
|
5-870.a1 + 5-401.12
|
BCT (< 1 quadrant) + SLNB (with color marking)
|
|
Scenario 1a
|
5-870.a1 + 5-401.12 + 5-406.11
|
BCT (< 1 quadrant) + SLNB (with color marking) + ALND (level I)
|
|
Scenario 1b
|
5-870.a1 + 5-401.12 + 5-406.12
|
BCT (< 1 quadrant) + SLNB (with color marking) + ALND (levels I and II)
|
|
Scenario 2
|
5-870.a1 + 5-401.13
|
BCT (< 1 quadrant) + SLNB (with radionuclide and color marking)
|
|
Scenario 2a
|
5-870.a1 + 5-401.13 + 5-406.11
|
BCT (< 1 quadrant) + SLNB (with radionuclide and color marking) + ALND (level I)
|
|
Scenario 2b
|
5-870.a1 + 5-401.13 + 5-406.12
|
BCT (< 1 quadrant) + SLNB (with radionuclide and color marking) + ALND (levels I and
II)
|
|
Scenario 3
|
5-870.a2 + 5-401.12
|
BCT (> 1 quadrant) + SLNB (with color marking)
|
|
Scenario 3a
|
5-870.a2 + 5-401.12 + 5-406.11
|
BCT (> 1 quadrant) + SLNB (with color marking) + ALND (level I)
|
|
Scenario 3b
|
5-870.a2 + 5-401.12 + 5-406.12
|
BCT (> 1 quadrant) + SLNB (with color marking) + ALND (levels I and II)
|
|
Scenario 4
|
5-870.a2 + 5-401.13
|
BCT (> 1 quadrant) + SLNB (with radionuclide and color marking)
|
|
Scenario 4a
|
5-870.a2 + 5-401.13 + 5-406.11
|
BCT (> 1 quadrant) + SLNB (with radionuclide and color marking) + ALND (level I)
|
|
Scenario 4b
|
5-870.a2 + 5-401.13 + 5-406.12
|
BCT (> 1 quadrant) + SLNB (with radionuclide and color marking) + ALND (levels I and
II)
|
|
Scenario 5
|
5-872.1 + 5-401.12
|
MRM + SLNB (with color marking)
|
|
Scenario 5a
|
5-872.1 + 5-401.12 + 5-406.11
|
MRM + SLNB (with color marking) + ALND (level I)
|
|
Scenario 5b
|
5-872.1 + 5-401.12 + 5-406.12
|
MRM + SLNB (with color marking) + ALND (levels I and II)
|
|
Scenario 6
|
5-872.1 + 5-401.13
|
MRM + SLNB (with radionuclide and color marking)
|
|
Scenario 6a
|
5-872.1 + 5-401.13 + 5-406.11
|
MRM + SLNB (with radionuclide and color marking) + ALND (level I)
|
|
Scenario 6b
|
5-872.1 + 5-401.13 + 5-406.12
|
MRM + SLNB (with radionuclide and color marking) + ALND (levels I and II)
|
Remuneration for inpatient treatment – DRG fees
The diagnosis and procedures performed in the patient cohort were categorized into
the appropriate DRGs and the fees were calculated ([Table 2]). The 13 investigated surgical scenarios were grouped into one of two DRGs: J07B
and J23Z. In accordance with § 8 of the Hospital Remuneration Act, services provided
prior to admission to the ward (including basic diagnostics and laboratory diagnostics)
could not be billed separately but were remunerated with the DRG fee. In the comparative
calculation, costs of materials and instruments were included in the flat-rate fee
per case. This also applied to standard contingency costs.
Table 2 DRG fees for inpatient diagnostics and treatment: classic (= relative DRG fee) and
hypothesized DRG fee per day (effective DRG fee/“day-case DRG”) compared to a theoretical
outpatient setting remunerated according to the EBM system.
|
Surgical scenario
|
OPS combinations
|
DRG
|
Relative DRG fee
|
Effective DRG fee/“day-case DRG”
|
EBM fee
|
Difference of inpatient to outpatient
|
% day-case DRG
|
|
Scenario 1
|
5-870.a1 + 5-401.12
|
J07B
|
€ 4580.47
|
€ 3351.72
|
€ 1313.81
|
€ 2037.91
|
39.20%
|
|
Scenario 1a
|
5-870.a1 + 5-401.12 + 5-406.11
|
J23Z
|
€ 5140.19
|
€ 2487.30
|
€ 1313.81
|
€ 1173.49
|
52.82%
|
|
Scenario 1b
|
5-870.a1 + 5-401.12 + 5-406.12
|
J23Z
|
€ 5140.19
|
€ 2487.30
|
€ 1313.81
|
€ 1173.49
|
52.82%
|
|
Scenario 2
|
5-870.a1 + 5-401.13
|
J07B
|
€ 4580.47
|
€ 3351.72
|
€ 1313.81
|
€ 2037.91
|
39.20%
|
|
Scenario 2a
|
5-870.a1 + 5-401.13 + 5-406.11
|
J23Z
|
€ 5140.19
|
€ 2487.30
|
€ 1313.81
|
€ 1173.49
|
52.82%
|
|
Scenario 2b
|
5-870.a1 + 5-401.13 + 5-406.12
|
J23Z
|
€ 5140.19
|
€ 2487.30
|
€ 1313.81
|
€ 1173.49
|
52.82%
|
|
Scenario 3
|
5-870.a2 + 5-401.12
|
J07B
|
€ 4580.47
|
€ 3351.72
|
€ 1313.81
|
€ 2037.91
|
39.20%
|
|
Scenario 3a
|
5-870.a2 + 5-401.12 + 5-406.11
|
J23Z
|
€ 5140.19
|
€ 2487.30
|
€ 1313.81
|
€ 1173.49
|
52.82%
|
|
Scenario 3b
|
5-870.a2 + 5-401.12 + 5-406.12
|
J23Z
|
€ 5140.19
|
€ 2487.30
|
€ 1313.81
|
€ 1173.49
|
52.82%
|
|
Scenario 4
|
5-870.a2 + 5-401.13
|
J07B
|
€ 4580.47
|
€ 3351.72
|
€ 1313.81
|
€ 2037.91
|
39.20%
|
|
Scenario 4a
|
5-870.a2 + 5-401.13 + 5-406.11
|
J23Z
|
€ 5140.19
|
€ 2487.30
|
€ 1313.81
|
€ 1173.49
|
52.82%
|
|
Scenario 4b
|
5-870.a2 + 5-401.13 + 5-406.12
|
J23Z
|
€ 5140.19
|
€ 2487.30
|
€ 1313.81
|
€ 1173.49
|
52.82%
|
|
Scenario 5
|
5-872.1 + 5-401.12
|
J23Z
|
€ 5140.19
|
€ 2487.30
|
€ 1205.31
|
€ 1281.99
|
48.46%
|
|
Scenario 5a
|
5-872.1 + 5-401.12 + 5-406.11
|
J23Z
|
€ 5140.19
|
€ 2487.30
|
€ 1205.31
|
€ 1281.99
|
48.46%
|
|
Scenario 5b
|
5-872.1 + 5-401.12 + 5-406.12
|
J23Z
|
€ 5140.19
|
€ 2487.30
|
€ 1205.31
|
€ 1281.99
|
48.46%
|
|
Scenario 6
|
5-872.1 + 5-401.13
|
J23Z
|
€ 5140.19
|
€ 2487.30
|
€ 1205.31
|
€ 1281.99
|
48.46%
|
|
Scenario 6a
|
5-872.1 + 5-401.13 + 5-406.11
|
J23Z
|
€ 5140.19
|
€ 2487.30
|
€ 1205.31
|
€ 1281.99
|
48.46%
|
|
Scenario 6b
|
5-872.1 + 5-401.13 + 5-406.12
|
J23Z
|
€ 5140.19
|
€ 2487.30
|
€ 1205.31
|
€ 1281.99
|
48.46%
|
Remuneration of theoretical surgical outpatient procedures based on the EBM
Based on § 4 of the AOP Contract, the cost of preoperative diagnostics for the patients
in our cohort who underwent BCT was calculated as € 688.80, and the cost of preoperative
diagnostics for the patients in our cohort who had MRM was calculated as € 459.02.
This included diagnostic imaging, punch biopsy, histology and staging (diagnosing
the extent of disease). The difference in costs between the two procedures is due
to the required wire marking and radiography of specimens from patients who undergo
BCT. The cost of preoperative laboratory diagnostics was calculated as € 21.15. It
should be noted that currently hospitals are not reimbursed for these costs.
According to § 5 of the AOP Contract, only intraoperative measures which have a direct
temporal and medical connection with the procedure are billable. This includes additional
procedures such as frozen section analysis of the sentinel lymph node for which the
remuneration is € 33.39.
When costing postoperative care, the EBM differentiates between postoperative monitoring
and postoperative treatment. In our patient cohort, postoperative monitoring was done
by the anesthesiologist, and postoperative treatment was provided by the surgeon.
Postoperative monitoring consisted of monitoring the patientʼs respiratory function,
circulation, and vigilance (obligatory care) as well as ECG monitoring and infusion
therapy (facultative care). In addition to examining and discussing the resected specimen(s),
the latter includes facultative services such as wound care and the removal of drainages
and sutures. According to § 7 para. 2 of the AOP Contract, 27.5% of the points must
be deducted from the points calculated for the surgeon. The legislators have justified
this deduction by stating that postoperative contacts between patient and surgeon
on the day of the operation and postoperative contact on the day after surgery is
part of the standard surgical service.
Two examples of billing for surgical procedures are depicted below: one for BCT, which
was carried out in 38 patients from our studied cohort ([Table 3]), and one for MRM ([Table 4]). MRM was carried out in 17 cases.
Table 3 Billing for breast-conserving therapy performed in an outpatient setting (OPS 5-870.a2
incl. 5-401.13 and 5-406.11).
|
BCT 5-870.a2 + 5-401.13 + 5-406.11
|
EBM no.
|
EBM points
|
Remuneration
|
|
Basic gynecology flat rate for insured patients aged 60 and above
|
08212
|
147
|
€ 15.10
|
|
Basic anesthesiology flat rate for insured patients aged 60 and above
|
05212
|
111
|
€ 11.40
|
|
Pre-anesthesia examination for a surgical procedure carried out in an outpatient setting
|
05310
|
179
|
€ 18.39
|
|
5-870.a2: partial (breast-conserving) breast excision surgery and destruction of breast
tissue: partial resection: coverage of the defect with mobilization and adaptation
of more than 25% of breast tissue (more than 1 quadrant)
|
31113
|
2343
|
€ 240.67
|
|
Anesthesia and/or general anesthesia, administered while carrying out a procedure
in accordance with fee schedule position 31 113
|
31823
|
1542
|
€ 158.39
|
|
5-401.13: Excision of individual lymph nodes and lymphatic vessels: axillary lymph
node dissection: with radionuclide and color marking, combined (sentinel lymphadenectomy);
category C2 procedure
|
31122
|
1542
|
€ 158.39
|
|
5-406 – 11: regional lymphadenectomy (dissection of several lymph nodes from a single
region) during a different procedure: axillary lymph node dissection: level 1; category
B2 procedure
|
31112
|
1602
|
€ 164.55
|
|
Postoperative monitoring following the surgical procedure in accordance with fee schedule
position 31 113
|
31504
|
743
|
€ 76.32
|
|
Postoperative treatment by surgeon minus 27.5% points (obligatory care: examination
of the specimen(s), discussion of specimen(s); billing: only one contact in the period
between the 1st and the 14th day after the procedure is billable)
|
31609
|
173
|
€ 12.88
|
|
Remuneration
|
|
|
€ 533.15
|
|
Flat-rate surcharge of 7% for materials
|
|
|
€ 37.32
|
|
Subtotal
|
|
|
€ 570.47
|
|
Preoperative diagnostics
|
|
|
€ 688.80
|
|
Laboratory diagnostics
|
|
|
€ 21.15
|
|
Intraoperative services
|
|
|
€ 33.39
|
|
Total reimbursement for breast-conserving therapy in an outpatient setting
|
|
|
€ 1313.81
|
Table 4 Billing for mastectomy carried out in an outpatient setting (OPS 5-872.1 incl. 5-401.12
and 5-406.11).
|
MRM 5-872.1 + 5-401.12 + 5-406.11
|
EBM no.
|
EBM points
|
Remuneration
|
|
Basic gynecology flat rate for insured patients aged 60 and above
|
08212
|
147
|
€ 15.10
|
|
Basic anesthesiology flat rate for insured patients aged 60 and above
|
05212
|
111
|
€ 11.40
|
|
Pre-anesthesia examination for a surgical procedure carried out in an outpatient setting
|
05310
|
179
|
€ 18.39
|
|
5-872.1: modified radical mastectomy: with resection of the pectoral fascia; category
B4 procedure
|
31114
|
3117
|
€ 320.17
|
|
Anesthesia and/or general anesthesia, administered while carrying out a procedure
as defined for fee schedule position 31 114
|
31824
|
1828
|
€ 187.77
|
|
5-401.12: Excision of individual lymph nodes and lymphatic vessels: axillary lymph
node dissection: with color marking, combined (sentinel lymphadenectomy); category
C2 procedure
|
31122
|
1542
|
€ 158.39
|
|
5-406 – 11: regional lymphadenectomy ((dissection of several lymph nodes from a single
region) during a different procedure: axillary lymph node dissection: level 1; category
B2 procedure
|
31112
|
1602
|
€ 164.55
|
|
Postoperative monitoring following the surgical procedure as defined for fee schedule
position 31 114
|
31504
|
743
|
€ 76.32
|
|
Postoperative treatment by the surgeon minus 27.5%
|
31611
|
233
|
€ 17.35
|
|
Remuneration
|
|
|
€ 646.50
|
|
Flat-rate surcharge of 7% for materials
|
|
|
€ 45.25
|
|
Subtotal
|
|
|
€ 691.75
|
|
Preoperative diagnostics
|
|
|
€ 459.02
|
|
Laboratory diagnostics
|
|
|
€ 21.15
|
|
Intraoperative services
|
|
|
€ 33.39
|
|
Total reimbursement for mastectomy performed in an outpatient setting
|
|
|
€ 1205.31
|
Although the surgical scenarios considered here consisted of two (BCT or MRM incl.
SLNB) or three (BCT or MRM incl. SLNB and ALND) procedures with different fee schedule
positions, no surcharges were payable for other procedures carried out simultaneously,
as simultaneous procedures are only billable if their diagnosis and surgical approach
differs from the main procedure. If several surgical procedures are carried out under
a single diagnosis, then only the procedure with the highest fee can be billed, in
this case either BCT or MRM. The fee for the surgical procedure (in this case EBM
no. 31113 and EBM no. 31114) covers all medical services provided by the surgeon,
examinations on the day of the procedure, final medical examinations after the procedure,
one postoperative contact between the physician and the patient, the documentation
of the surgical procedure and all consultations including the final report to the
physician responsible for further treatment. The EBM does not take account of differences
in the consumption of resources depending on the type, extent and severity of the
procedure. The flat-rate surcharge of 7% (§ 9 of the AOP Contract) of the total fee
covers all disposable materials, dressings, medicine and aids provided by the hospital.
Comparison of DRG fees and EBM fees
[Table 2] clearly shows the differences in the traditional remuneration using the DRG system,
the theoretical 1-day DRG and, for comparison, remuneration based on the EBM. What
is striking is the difference in the remuneration of comparable services when they
are performed in an outpatient and in an inpatient setting. This even applies to an
assumed 1-day DRG. The DRG remuneration is significantly higher for both BCT and MRM
compared to the remuneration for the same surgical procedures provided by the EBM
system. If hospitals were to carry out breast cancer surgery, which were previously
carried out as inpatient procedures, as outpatient procedures, then the remuneration
per procedure would be between 39.20 and 52.82% (average: 48.28%) of the DRG remuneration
per procedure (depending on the type and number of procedures), even under the assumption
of that the patient will only stay in hospital for 1 day. For example, based on the
average base rate of € 3311.98, the fee for a BCT carried out as a 1-day inpatient
treatment (OPS: 5-870.a1 or 5-870.a2) performed together with SLNB with color marking
(OPS: 5-401.12) or radionuclide and color marking (OPS: 5-401.13) and including preoperative
diagnostics would amount to € 3351.72. If the procedure were carried out in an outpatient
setting the hospital would receive fee of € 540.47 for the surgical procedure together
with € 688.80 for the preoperative diagnostics, € 21.15 for the laboratory diagnostics
and € 33.39 for intraoperative services, only amounting in total to € 1313.81. If
an MRM were carried out as in an outpatient setting, the hospital would receive a
total remuneration of € 1205.31 (amounting to approximately 48.46% of the DRG remuneration).
Discussion
In Germany oncological care is largely provided by certified centers which are supported
by service providers, the funding agencies and German healthcare policy in the context
of the National Cancer Plan. As regards senology, there are enough DKG- and DGS-certified
breast cancer centers to provide nationwide coverage [13]. Several publication have already shown that the care of patients with breast cancer
provided by certified breast cancer centers is currently not adequately remunerated,
and that surcharges are urgently required to cover the costs of the care provided
by certified facilities [14], [15], [16], [17]. The fact that certain additionally incurred costs are not reimbursable is particularly
problematic. Such additional costs include the expenses incurred for (re)-certification
and the cost of complying with obligatory quality criteria such as training and further
training, the costs of research based on molecular studies and clinical trials, and
the requirement of multiple documentation [18]. Detailed analyses have been done to show the cost of detailed documentation [3], [4]. Depending on the hospital or center costs range from € 352.82 to € 1084.08 for
documenting the overall course of treatment from the initial diagnosis to the conclusion
of follow-up in patients with breast cancer. Non-certified centers must fulfil fewer
requirements, leading to lower overall costs. Other costs incurred by certified centers
include the cost of coordinating the centers, support for patients and their families,
and the provision of infrastructures for interdisciplinary partners.
The establishment of a center followed by its certification is associated with significantly
higher additional costs, but the data shows that centers have a positive impact on
the quality of results. From the perspective of the health services, certified centers
are therefore cost-effective: they improve the quality of processes and results without
the funding agencies having to bear significantly higher costs. Although § 5 para.
2 of the Law on Hospital Fees (KHEntgG) does provide a legal basis for funding the
additional costs incurred by certified facilities, surcharges are seldom allowed [13], [16], [19]. Nevertheless, the certified centers still provide a range of services, usually
without surcharge, to ensure that patients receive adequate care. Certified centers
provide these unremunerated services because there is no wish to risk the high quality
of processes and results.
The unremunerated costs incurred by the centers contravene the goals of healthcare
policies, which aim to continually improve the quality of treatment and outcomes.
Rather than trying to combat the trend towards not remunerating services, inpatient
services are increasingly being concentrated into fewer days. The MDK is increasingly
monitoring the amount of time spent in hospital: the number of inpatients days are
being reduced and inpatient services are being replaced by outpatient procedures.
Shorter stays in hospital result in lower fees, pushing up cost pressures and increasing
the risk of underfunding.
The flat-rate fee per case should reflect the average stay in hospital of patients
receiving the appropriate treatment based on data collected by the InEK (Institute
for the Remuneration System in Hospitals) from sample hospitals [20]. To prevent patients in the G-DRG system from being discharged too early, significant
deductions are made if a hospital discharges patients quickly or if patients remain
in hospital for fewer days than the minimum stipulated length of stay. But the trend
of audits by the MDK has increasingly been not to approve some of the days that patients
spend in hospital, so that these patients then spend fewer than the minimum stipulated
days in hospital. From the perspective of the funding agencies, aspects such as psycho-oncologic
care, radioactive marking prior to SLNB, talks with the patient and her family, social-medical
counselling and other care services do not justify the patient staying in hospital.
The requirements for certified breast centers state that patients should not stay
in hospital for fewer than 4 days [21]. This requirement is based on the need for comprehensive holistic care around the
actual surgical procedure, care which includes medical-social and psycho-oncologic
care provided in hospital. Oncology patients treated in an outpatient setting have
only limited access to psycho-oncologic support and the waiting times for support
are usually long.
Under the motto “as much done in an outpatient setting as possible, as much done in
hospital as necessary”, more than ever before funding agencies and the MDK are demanding
that services be provided in an outpatient setting to slow down the rise in healthcare
expenditure. If women with breast cancer have surgical procedures in an outpatient
setting, this will exacerbate the current funding situation and intensify the cost
pressures even more.
To examine the potential impact of performing surgical procedures to treat patients
with breast cancer in an outpatient setting, this study developed a theoretical model
to compare surgical procedures carried out in hospital with those performed in an
outpatient setting. The comparison highlighted significant differences in remuneration
ranging from 39.20 to 52.82%. The differences were even more pronounced when the comparison
was between outpatient remuneration and real DRGs, not the theoretical 1-day DRG.
To take the example of mastectomy with SLNB and the additional resection of unmarked,
level 1 lymph nodes, the DRG remuneration for patient who stayed in hospital for an
average number of days would amount to € 5140.19. The remuneration according to the
EBM system would be € 1313.81; the difference in this case would amount to € 3826.38.
In this context it is important to consider the effect of the revenue-reducing discounts
levied against outpatient surgical procedures which are the result of the non-inclusion
of various procedures performed during breast-conserving surgery or mastectomy as
well as the deduction of 27.5% for postoperative treatment by the surgeon. Hospitals
which carry out procedures on an outpatient basis would have to absorb a loss of between
€ 164.97 (including SLNB and with a deduction of 27.5%) and € 329.53 (including SLNB,
ALND and a deduction of 27.5%). In addition, the cost of presenting individual cases
to an interdisciplinary tumor board including preparations for the board meeting is
not remunerated. Although this has been included in the EBM since October 10, 2015,
it is only described as a service provided as part of outpatient medical care (ASV)
as defined in § 116b of the SGB V and is therefore not relevant for the evaluation
in this study [22].
Even if the assumption that the current inpatient DRG remuneration covers the costs
were true, it must be stated that a comparable cost coverage could not be achieved
for either BCT or MRM performed on an outpatient basis. If there are no changes to
the legal and financial framework conditions, hospitals will not be able to provide
surgery for primary breast cancer in an outpatient setting in such a way that the
costs are covered. In addition to the problem of adequate remuneration described here,
this raises questions about the financing of the additional duties required of certified
centers as outlined above. These duties are not remunerated in an outpatient setting.
Taking MRM as an example, if the requisite surcharge of € 643.65 were to be added
for certified breast centers, a surcharge which patients consider to be justified
[23], then the difference in funding would amount to € 4470.03 for the same procedure
and services. Performing breast cancer surgery in an outpatient setting would lead
to a significant shortfall in remuneration. Moreover, the additional services provided
by certified centers which are currently being provided without surcharge or adequate
remuneration, such as coordination of the patient, interdisciplinary planning of therapy,
psycho-oncologic and social-medical care with involvement of family members, detailed
documentation, and ultimately the care provided by certified facilities, could no
longer be sustained. The quality of processes and results would be significantly at
risk.
This study has certain limitations. It is based on a purely theoretical model. It
should be noted that some of the analyzed surgical procedures are not currently listed
in the catalog of “Procedures carried out in an outpatient setting and other non-ward-based
in-hospital procedures in accordance with § 115b SGB V” [9]. Nevertheless, funding agencies are currently of the opinion that certain procedures
can be included in the AOP catalog and that the services could be provided in an outpatient
setting. Moreover, the actual points allotted regionally could differ from national
guidelines to take account of regional differences in costs and care facilities. Breast
reconstructive surgery was not included in the analysis. This was because of the complexity
of procedures and because performing breast reconstruction as an outpatient procedure
was not considered realistic. Finally, the actual costs of service providers could
be lower for procedures performed on an outpatient basis as the nursing costs and
cost of meals, etc. would be lower. The 1-day DRG was created to counteract this limitation.
The majority of costs are incurred at diagnosis and surgery, which are identical in
both scenarios.
Conclusion
The focus of the surgical treatment of patients with primary breast cancer must be
on providing multimodal treatment in compliance with medical guidelines with the active
involvement of well-informed patients and physician-patient contacts based on trust;
the focus should not be on measures which are driven by the pressure to save costs.
Hospitals and certified centers are not commercially driven facilities; they are demand-driven
facilities which discharge a social obligation to provide public healthcare services.
In addition to the numerous practical and moral arguments against performing breast
cancer surgery in an outpatient setting, this study shows that such a set-up would
also place a significant economic burden on hospitals because costs would not be covered.
