Author + information
- ↵⁎Reprint requests and correspondence:
Dr. Frank A. Flachskampf, Akademiska Sjukhuset, Ingång 40, plan 5, 751 85 Uppsala, Sweden
To offer a German perspective on reimbursement and its impact on cardiology practice, key features of the current system in Germany are presented.
Changes in the way cardiology is practiced and reimbursed in the United States—real and anticipated—have created frustrations and concerns among American cardiologists. Therefore it might be informative to look at other developed healthcare and reimbursement systems. In this paper, the authors intend to provide a concise although necessarily incomplete overview of the reimbursement system in cardiology in Germany and how it has affected cardiology practice.
German Cardiology Healthcare
German cardiology, in several respects, provides for an interesting comparison with its U.S. counterpart. Many characteristics are similar. There are no substantial waiting lists for medical procedures (except non-economically caused waiting lists [e.g., for heart transplants]), and there is no rationing. To illustrate the level of cardiology care serving the German population of 82 million inhabitants, who on average are considerably older than their American counterparts (percentage of population over 60 years old, 26% vs. 18%, respectively) (1,2), the following numbers indexed to 1 million inhabitants might be considered (latest available figures, all 2006 or later):
Cardiologists (3,4): Germany 49; United States 85
Coronary angiograms (3,5) Germany 10,573; United States 3,742 (inpatients only)
Percutaneous coronary interventions (PCIs) (3,5): Germany 3,792; United States 4,406 (inpatients only)
Coronary bypass surgery (5,6): Germany 715; United States 1,503
For 2008 total healthcare costs were estimated at 10.5% of the German gross domestic income—higher than, for example, in Great Britain (8.7%) but substantially lower than in the United States (16%) (7).
Importantly, the healthcare system, including cardiology, is consistently rated overall as adequate and efficient by the German public.
Health care in Germany is financed by a mixed system of “statutory” (Gesetzliche Krankenkassen) and private insurances, which cover very nearly the whole population. The statutory insurances are the default option insuring the vast majority of individuals (approximately 90%). The statutory insurance fee is a fixed percentage of the salary (currently 15.5%), one-half of which is paid for by the beneficiary, and one-half is paid for by the employer. Unemployed individuals are insured in a statutory insurance at the expense of the state. Statutory insurances also cover the family of the employee at no extra cost. All major health costs, including drugs, are paid for, except for small additional fees (e.g., for each outpatient visit, and a per-day fee for hospital stays). Approximately 10% of the population is privately insured; this option can only be chosen by salaried individuals above a certain income level or by state employees. Private insurance fees depend on the extent of services insured (e.g., dental work), co-payments, amenities like single- or double-room hospital accommodation, in-hospital treatment by the chief of the department, and others. Family members are insured at extra cost in private insurance.
Most hospitals are publicly owned or owned by nonprofit organizations; these hospitals finance their costs of operation, including salaries of healthcare personnel, material costs and the like from case-based reimbursement of healthcare services by the insurers; however, major hospital investments, mostly those related to construction, are publicly financed (i.e., from taxes). One-third of all hospitals are privately owned and also receive reimbursement for operational costs from health insurances as the former group of hospitals. Cardiology outpatient care is mainly delivered by cardiologists and internists in private practice.
For hospitals, reimbursement is determined by a diagnosis-related groups (DRG) or “flat fee” principle: the documented final diagnosis together with other factors like comorbidities and length of hospital stay determine the amount of money that the insurance reimburses to the hospital/admission. This holds for both statutory and private insurance; the latter reimburses additionally in a fee-for-service manner personal treatment by specific hospital physicians—usually the department chiefs—and certain amenities like better accommodation, making it desirable for hospitals to attract privately insured patients.
Although the principle of a flat fee for a given diagnosis should financially discourage extensive use of resources, procedures play a powerful role in the German reimbursement system, because they modify the final diagnosis code. For a better understanding, consider the following schematic scenarios involving patients admitted to a hospital due to acute chest pain, in whom an acute myocardial infarction is initially ruled out (Table 1). Statutory insurance is assumed. All cited sums are approximative and vary considerably, depending on location, insurance company involved, capped volumes, and other details; a 1:1.4 exchange rate €/$ was assumed:
1. In Patient A an exercise electrocardiogram (ECG) and an echo are performed, which are unremarkable, and the patient is released on Day 2. The typical DRG-based reimbursement is $832 (€594).
2. Patient B on the second day undergoes coronary angiography. Diffuse coronary artery disease is seen without a lesion deemed suitable for intervention. He is released home on Day 3. Although the coronary angiography as such is not reimbursed, it serves as a justification for an additional hospital day, bringing the typical reimbursement to $2,100 (€1,500).
3. Patient C also undergoes coronary angiography. A coronary stenosis is seen, and an intervention is performed with implantation of a drug-eluting stent (cost of stent: approximately $800); the patient is released on Day 3. The typical DRG-based reimbursement, including stent costs, is $4,712 (€3,366).
For outpatients, the statutory insurances pay a very low flat fee/patient/quarter of the year, currently approximately $84, as long as at least an echo is performed in addition to physical examination and ECG, regardless of additional ambulatory tests or treatments. For private outpatients, however, the cardiologist can charge on a fee-for-service basis. To illustrate this, again 3 schematic outpatient statutory insurance scenarios for patients with chronic chest pain are outlined (Table 1):
1. In Patient A, a physical and laboratory examination, a resting ECG, an echocardiogram, and an exercise test are performed. The typical reimbursement for a patient with statutory insurance is the previously cited flat sum, approximately $84, paid once/patient/quarter of the year, regardless of the number of visits. If the patient has private insurance, these 4 examinations can be billed individually.
2. In Patient B, an additional stress echo is performed. A new wall motion abnormality is seen at peak bicycle exercise, and the patient is scheduled for an outpatient coronary angiography. The latter reveals no critical lesions. For an outpatient with statutory insurance, beyond the flat fee there is no additional reimbursement for the stress echo; for the coronary angiography, material costs and post-procedure monitoring are compensated by a fixed sum of approximately $388 (€277). If the patient is privately insured, both stress echo and the coronary angiography are reimbursed, the latter considerably higher.
3. In Patient C, workup is as for patient B, but on angiography a coronary stenosis is seen. A PCI is performed with implantation of a drug-eluting stent, and the patient is admitted for 1 night to a hospital, bringing reimbursement for patients in statutory insurance to approximately $3,571 (€2,551) and considerably higher if the patient is privately insured.
As these schematic examples show, the reimbursement system inordinately favors performing procedures such as PCI, whereas conservative (and preventive) efforts in comparison result in very low compensation. Not surprisingly, this has affected and continues to affect the practice of cardiology. Over the past 20 years, the number of catheterization laboratories in Germany grew from 234 to 830, and procedure rates rose dramatically (3): coronary angiography rates more than quadrupled, and PCIs increased almost 10-fold (Fig. 1). The resulting per-capita number of procedures by far outstrip the corresponding figures in other European countries (8), including those with similar healthcare standards (Fig. 2).
A particularly unfortunate consequence of the system is that noninvasive tests such as stress tests or cardiac imaging, both in-hospital or in the outpatient setting, do not generate any compensation from statutory insurance. Furthermore, if their consequence is conservative treatment, the hospital or the practicing physician barely break even or incur a financial loss.
It has been debated hotly whether there is deliberate overuse of procedures for financial reasons in Germany (9–11). This cannot be established on the basis of the available data. For example, a study analyzing appropriateness of cardiovascular interventions in Germany in the years 2000 to 2001 found only 2% of PCI clearly inappropriate, although 41% of PCI were deemed of uncertain appropriateness (12). Alternatively, some observers have suggested that German cardiology might just be pioneering a more invasive approach to coronary heart disease, with other European countries lagging behind for a variety of reasons (10,13). The decreasing hospital mortality of myocardial infarction and generally of ischemic heart disease in Germany certainly suggest that the management of ischemic heart disease has been successful overall. However, in comparison with European countries similar to Germany by age structure, lifestyle, gross national product, and healthcare system (e.g., the Netherlands), it is notable that:
• numbers of coronary angiographies and percutaneous interventions/capita are much higher in Germany (Fig. 2);
• there is a clearly lower ratio of coronary interventions to coronary angiograms in Germany (0.36 vs. 0.50 in the Netherlands); and
• mortality from heart disease in the Netherlands is lower than in Germany (standardized death rate, 43/100,000 inhabitants) than in Germany (standardized death rate, 43/100,000 inhabitants) (14).
The diagnosis-related group, “flat-fee” reimbursement system might in theory enable better allocation of resources than a fee-for-service principle. In the current German realization of this idea, however, an originally perhaps reasonable bonus system for performing costly procedures has become the financial driver of the system, in particular because of an unsustainably low level of reimbursement of conservative management. Thus, although the past stunning expansion of procedure numbers certainly is multifactorial, the present reimbursement rules are deeply dysfunctional, in particular in light of current understanding of proper management of coronary artery disease. The present rules financially penalize conservative clinical management, de-emphasize ischemia testing, and continue to encourage invasive procedures. These features need to be corrected to align the financial logic with medical reason.
Please note: All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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