Flat rates per case: outpatient before inpatient, but…

In Germany, too many cases have long been treated in hospitals that could easily be treated without hospitalization. Older figures show that in Denmark in 2018 only around 13 percent of inguinal hernia operations were carried out on an inpatient basis, while in Germany almost all were. The situation is similar with the removal of the gallbladder: in Germany this involves a hospital stay in all cases, in Great Britain and Denmark only in around half of the cases.

Would more interventions without an inpatient stay carried out, nursing staff could be saved, which could then be used for more seriously ill patients. However, the health system as it is currently structured is struggling to make progress in the area of ​​outpatient care. One of the ideas for achieving the latter is the so-called hybrid DRGs – i.e. flat rates per case that could also be billed on an outpatient basis.

Health experts have been working on the topic of outpatient care since the mid-1990s. Paragraph 115b of the Social Code V, which regulates outpatient surgery, dates back to 1993. However, because hospitals increased their case numbers with the help of Diagnosis Related Groups (DRGs), the number of outpatient procedures in these locations did not exceed two million cases per year between 2004 and 2020 – compared to the total number of cases during this period of 16 .8 to 19.4 million annually.

In a report from 2022, the stagnation in outpatient procedures was also attributed to the fact that the AOP catalog has hardly been expanded since 2005. This catalog is about operations or diagnostic procedures that hospitals are allowed to carry out on an outpatient basis. In addition, the remuneration is higher in inpatient cases than in outpatient cases.

The AOP catalog was then further developed in two steps: It was expanded from 2,881 services to 3,312 services and, from last year, also allows differentiation according to severity levels. Since the beginning of 2024, there may be a surcharge for the care of fractures and dislocated or dislocated joints. Statutory health insurance companies assume that in the future, inpatient admission will be dispensed with in a further 500,000 cases per year.

In 2022, however, the Hospital Care Relief Act made sector-equal remuneration possible by adding a paragraph f to Section 115 mentioned above. This is where hybrid DRGs came into play, which reward services equally regardless of whether they are carried out in an inpatient or outpatient setting. This meant that there were two parallel approaches with the same goal of outpatient care.

Shortly before Easter, the hybrid DRGs reached an agreement for the 2025 service catalog. The National Association of Statutory Health Insurance Physicians, the hospital association and the umbrella association of statutory health insurance were involved. 90 additional codes were included in the agreement, for example for certain biopsies and ultrasound examinations or for procedures for small bone fractures. The codes must be calculated by the end of the year, and flat rates per case are then agreed on this basis. The total volume for the new DRGs alone is 200,000 outpatient cases.

From a cash perspective, the parallel approach ultimately results in higher costs than necessary. Only services from the AOP catalog may be remunerated as hybrid DRGs. However, the development of the latter appears to be more orderly compared to the service catalog of the hybrid DRGs, which still needs to be updated. There is also a fear among statutory health insurance funds that Resident doctors benefit from thisthat with the help of DRGs they can achieve significantly higher remuneration for services that they already provide on an outpatient basis. There is unrest among doctors because of unclear billing modalities, such as the distribution key for operating teams. Also because of its importance for hospital reform, the topic will remain in the debate for the foreseeable future.