Remuneration of Hospital Emergency Services

Abstract (English)

Flates rates based on Diagnosis Related Groups (DRGs) are introduced in a growing number of countries to remunerate acute inpatient treatment. Doing so, one will have to decide – among other things – whether the inpatient emergency services should be remunerated apart from the DRG flat rates or as part of them. Without apart remuneration, there may be the apprehension that wrong economic incentives with regard to emergency services could develop. To be able to decide about an apart remuneration of emergency readiness and/or emergency treatment one must know how to categorise services, which are the costs of emergencies and how the remuneration can be derived from them.

By means of internet exploration, the author describes different solutions of emergency patient classification systems and emergency flat rates from France, United Kingdom, and New South Wales (Australia). Besides, he shows approaches to regulations from Switzerland, Germany, United States, Canada, and Victoria (Australia). Out of the collected informations (state of year 2008), he compiled suggestions as help to decide if eventually elevated emergency costs will justify apart remuneration and how this could be modelled.

In France, a yearly flat rate based on the size of the emergency ward/departement is payed to remunerate emergency readiness. (The size of the emergency ward is calculated based on the budgeted number of emergency attendances.) Emergency admissions (emergencies with subsequent inpatient admission) are payed by GHS flat rates (GHS = "Groupes homogènes de séjours" = french DRG flat rates). Out­patient emergency attendances are payed by a flat rate of € 25.

In the United Kingdom, different HRG flat rates are defined for elective and non-elective cases (HRGs = Healthcare Resource Groups = british DRGs). Thus, 10 % of the remuneration volume are redistributed. (Non-elective cases encompass not only emergencies but also births, newborns, and transfers.) Additionally, there is an threelevel emergency tariff to remunerate for inpatient and outpatient emergency attendances. It is defined by means of about 10 emergency HRGs. 80 % of the emergency tariff is payed based on the planned emergency attendances in order to cover emergency readiness. This is done regardless of the actual number of emergency attendances ("80/20 rule"). This emergency flat rates are payed for emergency admissions in addition to the non-elective HRG flat rate. 50 % of the latter are payed based on the planned number of emergency admissions, 50 % due to the actual admissions ("differential tariff").

In New South Wales (Australia), emergency services are categorized into seven levels according to their roles and staffing. 80 % of the emergency costs (for inpatient and outpatient cases) are payed by a budget for emergency readiness. To do this, the planned cases are weighted by means of the emergency patient classification system UDG ("Urgency and Disposition Groups") which defines 11 patient categories. Three base rates are used according to the hospital types. (The three hospital types are: "general referral hospitals" or "large metropolitan districts"; "childrens"; "small metro districts" or "rural base".) The remaining 20 % of the emergency costs are payed by UDG weighted emergency flat rates. For emergency admissions, an ARDRG flat rate is payed additionally.

In Switzerland, acute inpatient treatment will be remunerated from 2012 onward by the SwissDRG-System, an adapted GDRG-System. By a law rule introduced at the end of 2007, the new flat rates must not contain public welfare services. Hence, emergency readiness has to be calculated and remunerated apart from DRG flat rates, independently of the number of cases.

In Germany, there is no apart remuneration for emergency admissions. On principle, Hospitals are ordered to participate to emergency services. Hospitals which do not participate have to reckon in a deduction of € 50 per case.

The main suggestions out of several suggestions are: Emergency readiness should be defined and remunerated by performance contracts. A bonus system could promote the attainment of certain emergency targets. To be able to judge the costs of emergency treatment, all DRGs should be splitted by the criterium "with/without emergency attendance". Thus, "emergency attendance" must be defined. A medical definition is suggested like: "Emergency attendances are attendances of patients who are required to be treated within x (e. g. 12) hours." If cost differences are seen, they can be represented by apart DRG weights for DRGs "with emergency attendance" and DRGs "without emergency attendance".