RESUMO
INTRODUCTION: Hospital inpatient stays are reimbursed on the basis of German diagnosis-related groups (G-DRG). The G-DRG classification system is based on complex coding guidelines. The Medical Review Board of the Statutory Health Insurance Funds (MDK) examines the encoding by hospitals and delivers individual expertises on behalf of the German statutory health insurance companies in cases in which irregularities are suspected. A study was conducted on the inter-rater reliability of the MDK expertises regarding the scope of the assessment. METHODS: A representative sample of 212 MDK expertises was taken from a selected pool of 1 392 MDK expertises in May 2013. This representative sample underwent a double-examination by 2 independent MDK experts using a special software based on the 3MTM G-DRG Grouper 2013 of 3M Medica, Germany. The following items encoded by the hospitals were examined: DRG, principal diagnosis, secondary diagnoses, procedures and additional payments. It was analysed whether the results of MDK expertises were consistent, reliable and correct. RESULTS: 202 expertises were eligible for evaluation, containing a total of 254 questions regarding one or more of the 5 items encoded by hospitals. The double-examination by 2 independent MDK experts showed matching results in 187 questions (73.6%) meaning they had been examined consistently and correctly. 59 questions (23.2%) did not show matching results, nevertheless they had been examined correctly regarding the scope of the assessment. None of the principal diagnoses was significantly affected by inconsistent or wrong judgment. CONCLUSION: A representative sample of MDK expertises examining the DRG encoding by hospitals showed a very high percentage of correct examination by the MDK experts. Identical MDK expertises cannot be achieved in all cases due to the scope of the assessment. Further improvement and simplification of codes and coding guidelines are required to reduce the scope of assessment with regard to correct DRG encoding and its examination.
Assuntos
Grupos Diagnósticos Relacionados/estatística & dados numéricos , Prova Pericial/estatística & dados numéricos , Prova Pericial/normas , Programas Nacionais de Saúde/estatística & dados numéricos , Competência Profissional/estatística & dados numéricos , Garantia da Qualidade dos Cuidados de Saúde/estatística & dados numéricos , Grupos Diagnósticos Relacionados/normas , Prova Pericial/legislação & jurisprudência , Honorários e Preços , Alemanha , Hospitalização/estatística & dados numéricos , Programas Nacionais de Saúde/normas , Garantia da Qualidade dos Cuidados de Saúde/normas , Métodos de Controle de Pagamentos/normas , Métodos de Controle de Pagamentos/estatística & dados numéricosAssuntos
Tabela de Remuneração de Serviços , Honorários Médicos/legislação & jurisprudência , Reforma dos Serviços de Saúde/economia , Medicare Payment Advisory Commission/legislação & jurisprudência , Métodos de Controle de Pagamentos , Mecanismo de Reembolso/legislação & jurisprudência , Honorários Médicos/normas , Honorários Médicos/tendências , Humanos , Política , Métodos de Controle de Pagamentos/legislação & jurisprudência , Métodos de Controle de Pagamentos/normas , Tennessee , Estados UnidosAssuntos
Centers for Medicare and Medicaid Services, U.S./economia , Garantia da Qualidade dos Cuidados de Saúde/economia , Métodos de Controle de Pagamentos/normas , Reembolso de Incentivo/normas , Centers for Medicare and Medicaid Services, U.S./legislação & jurisprudência , Humanos , Legislação Hospitalar/economia , Assistência de Longa Duração/economia , Assistência de Longa Duração/legislação & jurisprudência , Pessoas sem Cobertura de Seguro de Saúde , Patient Protection and Affordable Care Act/economia , Patient Protection and Affordable Care Act/normas , Garantia da Qualidade dos Cuidados de Saúde/legislação & jurisprudência , Métodos de Controle de Pagamentos/legislação & jurisprudência , Reembolso de Incentivo/legislação & jurisprudência , Estados UnidosAssuntos
Seguro Saúde/economia , Administração da Prática Médica/economia , Métodos de Controle de Pagamentos/normas , Mecanismo de Reembolso/normas , Serviços Contratados/economia , Serviços Contratados/normas , Humanos , Seguro Saúde/organização & administração , Relações Interinstitucionais , Negociação , Administração da Prática Médica/organização & administração , Métodos de Controle de Pagamentos/métodos , Mecanismo de Reembolso/tendênciasAssuntos
Agências de Assistência Domiciliar/economia , Medicare/economia , Métodos de Controle de Pagamentos/normas , Controle de Custos/métodos , Fraude/economia , Fraude/prevenção & controle , Agências de Assistência Domiciliar/normas , Humanos , Medicare/normas , Métodos de Controle de Pagamentos/métodos , Estados UnidosRESUMO
Sweden has experienced a national value-based pricing (VBP) system for innovative outpatient drugs operated by the Pharmaceutical Benefits Board - LFN (now called the Dental and Pharmaceutical Benefits agency - TLV) since 2002. VBP has the character of a monopoly system, leading to reimbursement decisions where usage of new medicines is limited to subgroups and not the population for which the drug is approved. VBP relies on a broad societal perspective, encouraging innovations by signaling to firms that value-adding treatments are demanded. However, the VBP system is operated without a drug budget responsibility. The budget responsibility lies at the regional level, not operating VBP, thus an intrinsic conflict is built into the system. The aim of this article is to suggest a modification to the current reimbursement system in Sweden where payment for pharmaceuticals is split between the regional and national levels. The system is expected to make new innovative pharmaceuticals accessible to a larger number of patients and provide more consumer surplus without reducing the producer surplus. In short, the county councils pay the marginal cost of production while the state pays for the innovation.