Simulation of reimbursement based on valid data and real assumptions
Cost-benefit analysis of medical procedures
Rapid evaluation of economic effort and reimbursement
When creating economic models, possible treatment paths are described in terms of their economic cost. If all requirements are met, new procedures are financed via NUB fees until they can be incorporated into the aG-DRG system. For new procedures that enable significant in-hospital cost savings, refinancing is based on these same characteristics. The principle of the better applies here.
Cost-effectiveness requirement according to § 12 SGB V
“The services must be sufficient, appropriate and economical; they must not exceed what is necessary. Services that are not necessary or uneconomical may not be claimed by insured persons, may not be effected by service providers, and may not be approved by health insurance funds.”
If a procedure (with or without the use of a medical product) is shown to have a relevant evidence-based benefit, e.g. in the form of a reduction in the length of stay, a reduction in the need for reoperations, or a reduction in complication rates compared with the comparative therapy, this economic benefit can be depicted in an economic model.
New or improved therapeutic approaches are usually associated with higher costs. If these costs can be set against in-hospital benefits (savings potential for the hospital) or an additional patient-relevant benefit (savings potential at the macroeconomic level), it may be useful to present the savings potential using an economic model.
Note: Savings potential in the form of a reduction in length of stay or a reduction in pre-, intra- or postoperative complications is to be considered in the aG-DRG system as an already existing reimbursement. This is due to the retrospective calculation basis, which is based on currently valid revenues on the basis of services and costs from two years ago. If the therapy is improved, which two years ago caused longer lengths of stay, complications or other higher costs, this progress must be taken into account.
Economy model or NUB request?
1. In the NUB inquiry form, it is asked to describe the existing method that is to be replaced by the new examination and treatment method. Thus, a comparison is made between already calculated and thus included costs, and the costs that the new method will cause.
Plain text: The established therapy causes average costs at a value of € 1,000.00. The new, improved therapy is expected to cost € 2,000.00. The remaining difference in costs is € 1,000.00 (note: additional costs must always be offset by a relevant benefit!).
2. In the NUB inquiry form, it is asked to describe the expected effect on the length of stay. Due to the flat-rate reimbursement amount between the lower and upper limit length of stay, each day that the patient recovers sooner is to be considered a monetary benefit.
Plain text: The new examination and treatment method demonstrably shortens the hospital stay by 3 days. The postoperative day of stay in the normal ward costs ~ € 300.00 (estimated price!). Of the differential price of € 1,000.00, only € 100.00 of “real additional costs” remain.
These examples only serve as an illustration and for a better understanding of the assessment of when it is a matter of significant additional costs in the sense of the system, which are to be compensated via NUB charges. For procedures to which this illustrative model can be applied, an economic model may be preferable to the NUB request.