Context
In Germany, the organization and financing of hospital and ambulatory care are separated. Several instruments were installed over the years to provide high-quality patient-centred care and to overcome the split between the two sectors. These include pre- and post-inpatient care, that is, hospital treatments without an overnight stay to prepare for or follow-up on an inpatient stay. Also, day care is typically provided in specific day care clinics, mostly covering psychiatric and geriatric care. Thirdly, hospitals can offer outpatient/day-case surgery for a limited number of treatments. For these, hospitals receive the same remuneration as office-based physicians. Despite these efforts, specialized care remains largely separated between hospital and ambulatory care.
Two further instruments are currently being installed to promote intersectoral, patient-centred care and to free up highly needed human and financial resources. The instruments are based on a recommendation from the Government Commission for a Modern and Needs-Based Hospital Sector (See Country Update of 5 November 2022) [1]. They were initiated by the Act on Nurse Staffing and other Regulations in the Hospital Sector (Krankenhauspflegeentlastungsgesetz), which passed parliament in December 2022 [2].
Reform content
Changes to the regular inpatient stay
As of February 2023, hospitals can offer certain patients admitted on an inpatient basis the possibility to leave the hospital overnight [3,4] under the following prerequisites:
- they are acceptable from a medical point of view, which is to be decided individually for each case by the hospital/attending physician;
- the inpatient treatment during the day is of at least six hours;
- the patient’s approval.
Remuneration for the new “day inpatient care” is provided via the regular Diagnosis Related Groups (DRG) system for inpatient care, but a certain amount is deducted for every night the patient stays at home, regardless of diagnosis and treatment (about €160/night). The deduction is limited to 30% of the amount the hospital would have received for a regular inpatient stay.
Equal remuneration for both hospitals and outpatient specialists for specific procedures (Hybrid DRG)
The Act on Nurse Staffing and other Regulations in the Hospital Sector also obliged the self-governing bodies to agree on a new form of cross-sectoral remuneration to be valid for both office-based ambulatory physicians and hospitals, calculated on a per-case basis (“hybrid DRG”). The new remuneration form should be limited to procedures already eligible for outpatient/day-case surgery, especially procedures with a high number of inpatient cases, short lengths of stay, and low clinical complexity [5].
Since the self-governing bodies did not reach an agreement by March 2023, it is up to the Ministry of Health to determine the exact reimbursement criteria and the list of appropriate procedures. This is expected to happen in the second half of 2023 in order to start the new remuneration at the beginning of 2024 [6].
The reforms represent further efforts to lower sector boundaries between inpatient and outpatient care. For the hybrid DRGs, the remuneration details and the number of services included will determine how well service providers will accept the new approach. The implementation of hybrid DRGs will be evaluated in April 2024, and the change to regular inpatient stays in July 2024.