How is intensive care reimbursed? A review of eight European countries

Martin-Immanuel Bittner 0 Maria Donnelly Arthur RH van Zanten Jakob Steen Andersen Bertrand Guidet Jose Javier Trujillano Cabello Shane Gardiner Gerard Fitzpatrick Bob Winter Michael Joannidis Axel Schmutz 0 0 Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Freiburg , Hugstetter Str. 55, Freiburg D-79106, Germany Reimbursement schemes in intensive care are more complex than in other areas of healthcare, due to special procedures and high care needs. Knowledge regarding the principles of functioning in other countries can lead to increased understanding and awareness of potential for improvement. This can be achieved through mutual exchange of solutions found in other countries. In this review, experts from eight European countries explain their respective intensive care unit reimbursement schemes. Important conclusions include the apparent differences in the countries' reimbursement schemes-despite all of them originating from a DRG system-, the high degree of complexity found, and the difficulties faced in several countries when collecting the data for this collaborative work. This review has been designed to assist the intensivist clinician and researcher in understanding neighbouring countries' approaches and in putting research into the context of a European perspective. In addition, steering committees and decision makers might find this a valuable source to compare different reimbursement schemes. - Introduction Over the recent years, research regarding costing and reimbursement have gained growing appreciation within the field of intensive care. One reason may be that intensive care units (ICUs) are considered to be the most expensive departmental structures in hospitals [1]. High costs of personnel, complex procedures and expensive medical devices, equipment, and infrastructure contribute to this fact [2-4]. Intensive care costs play an important role in hospital economicsboth for the respective intensive care unit, the hospital it belongs to, and the healthcare system eventually reimbursing the costs. Several studies have analysed the generation of costs in ICUs, partly also comparing procedures in different countries [5,6]. However, to date there is no widely accessible information in a scientific setting about how costs are reimbursed in the ICU setting in different countries. However, the adequate reimbursement of costs is of paramount importance for ICUs. Therefore, national experts for ICU reimbursement and costing issues were contacted and asked for collaboration (see Table 1 for the original questionnaire). The primary goal of this collaborative effort was to give a comprehensive overview about how reimbursement works in a selection of European countries. A diversified convenience sample of eight European countries has been chosen to represent the differences in the European ICU setting. The inclusion of national experts was the key to be able to identify and explain the national systems, in many cases only rendered possible through their personal experience in the respective countrys system (thereby not even taking into account language barriers). The information generated by this amalgamation of different countries perspectives can be used to enhance mutual knowledge about problems faced and approaches found elsewhere (see Table 2 for a general overview on the countries healthcare systems). This also can be valuable for informing policymakers, directly influencing amendments and corrections to the systems currently used. It has to be highlighted that the Table 1 Original questionnaire used to inform all authors about uniform requirements Health system key facts ICUs key facts - Principal mode of financing (e.g., tax-based, insurance-based) - Number of patients admitted to hospitals per year (country-wide) - Number of patients admitted to ICUs per year (country-wide) - Number of ICUs (country-wide) Please describe in detail, how ICU costs are being measured and how the reimbursement is being calculated; please refer to the clinical routine, as used in daily work: - Necessary documentation (is there extra documentation for budgeting purposes, or is the standard clinical documentation used?) - Coding (e.g., in a DRG-based system, where reimbursement is linked to diagnosis) - Are there differences concerning reimbursement of surgical vs. medical intensive care unit patients - Are there differences concerning reimbursement schemes for teaching hospitals and non-teaching hospitals (teaching refers to the education of physicians) - Possible modifiers (e.g., when a patient has to receive expensive medication, develops complications etc.) - What are, in your opinion, the most important advantages and disadvantages of your reimbursement scheme - Personal opinion: please explain, if you perceive a major imbalance between costs and reimbursement, i.e., if the reimbursement scheme does not adequately reflect the necessary clinical care Please give references for the statements made; please feel free to include additional study results into the personal opinion part (e.g., a study conducted in your country validating your opinion or adding a crucial point) differing reimbursement schemes employed in European ICUs also directly affect healthcare costs. We hope that this overview is to be seen as a valuable tool for other researchers working in the field of ICU cost-reporting and cost-generation, who might find it useful to place their findings into a European context. In the following sections, the national systems will be explained by the respective national expert. Review Germany The German reimbursement scheme is in general based on a DRG system (diagnosis-related groups). The basic concept is the combination of a main diagnosis derived from the ICD-10 (International Statistical Classification of Diseases and Related Health Problems 10th Revision) catalogue and secondary diagnoses as well as procedures listed in the OPS-301 (Operationen- und Prozedurenschluessel = operations and procedures classification) catalogue to form a basic DRG code. This basic DRG code can be modified according to the Patient Clinical Complexity Level, yielding the final DRG code which is reimbursed [18]. Compared with the original version, the System Version 2010 included many new features dealing with the special needs of ICUs. The 2010 system was made substantially more complex with the aim of improving the correlation between costs and reimbursements in the intensive care setting [19]. Key components of the German reimbursement scheme in the ICU setting include the possibility of varying existing diagnoses by making amendments which specify the individual patients health status. The first specification is the length of mechanical ventilation. It can be coded in intervals starting with a minimum length of 96 h. The second is the so-called intensive care complex treatment. This is an additional feature which is bound to prerequisites, (...truncated)