RESUMEN
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.
Asunto(s)
Grupos Diagnósticos Relacionados/estadística & datos numéricos , Testimonio de Experto/estadística & datos numéricos , Testimonio de Experto/normas , Programas Nacionales de Salud/estadística & datos numéricos , Competencia Profesional/estadística & datos numéricos , Garantía de la Calidad de Atención de Salud/estadística & datos numéricos , Grupos Diagnósticos Relacionados/normas , Testimonio de Experto/legislación & jurisprudencia , Honorarios y Precios , Alemania , Hospitalización/estadística & datos numéricos , Programas Nacionales de Salud/normas , Garantía de la Calidad de Atención de Salud/normas , Método de Control de Pagos/normas , Método de Control de Pagos/estadística & datos numéricosAsunto(s)
Tabla de Aranceles , Honorarios Médicos/legislación & jurisprudencia , Reforma de la Atención de Salud/economía , Medicare Payment Advisory Commission/legislación & jurisprudencia , Método de Control de Pagos , Mecanismo de Reembolso/legislación & jurisprudencia , Honorarios Médicos/normas , Honorarios Médicos/tendencias , Humanos , Política , Método de Control de Pagos/legislación & jurisprudencia , Método de Control de Pagos/normas , Tennessee , Estados UnidosAsunto(s)
Centers for Medicare and Medicaid Services, U.S./economía , Garantía de la Calidad de Atención de Salud/economía , Método de Control de Pagos/normas , Reembolso de Incentivo/normas , Centers for Medicare and Medicaid Services, U.S./legislación & jurisprudencia , Humanos , Legislación Hospitalaria/economía , Cuidados a Largo Plazo/economía , Cuidados a Largo Plazo/legislación & jurisprudencia , Pacientes no Asegurados , Patient Protection and Affordable Care Act/economía , Patient Protection and Affordable Care Act/normas , Garantía de la Calidad de Atención de Salud/legislación & jurisprudencia , Método de Control de Pagos/legislación & jurisprudencia , Reembolso de Incentivo/legislación & jurisprudencia , Estados UnidosAsunto(s)
Seguro de Salud/economía , Administración de la Práctica Médica/economía , Método de Control de Pagos/normas , Mecanismo de Reembolso/normas , Servicios Contratados/economía , Servicios Contratados/normas , Humanos , Seguro de Salud/organización & administración , Relaciones Interinstitucionales , Negociación , Administración de la Práctica Médica/organización & administración , Método de Control de Pagos/métodos , Mecanismo de Reembolso/tendenciasAsunto(s)
Agencias de Atención a Domicilio/economía , Medicare/economía , Método de Control de Pagos/normas , Control de Costos/métodos , Fraude/economía , Fraude/prevención & control , Agencias de Atención a Domicilio/normas , Humanos , Medicare/normas , Método de Control de Pagos/métodos , Estados UnidosAsunto(s)
Medicare/economía , Método de Control de Pagos/normas , Mecanismo de Reembolso/normas , Tabla de Aranceles/normas , Tabla de Aranceles/tendencias , Humanos , Medicare/normas , Medicare/tendencias , Política , Método de Control de Pagos/tendencias , Mecanismo de Reembolso/tendencias , Estados UnidosRESUMEN
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.