von Stillfried D, Czihal T, Jansen K
Zentralinstitut für die Kassenärztliche Versorgung in der Bundesrepublik Deutschland.
Gesundheitswesen. 2011 Mar;73(3):124-33. doi: 10.1055/s-0030-1252040. Epub 2010 Jun 9.
The financial dimension of long term changes in the medical division of labour between inpatient care and ambulatory care has yet to be systematically monitored. While this is of general interest for health systems research there is now an acute need for the development of reliable methods to measure the effects of shifts in care as part of physician payment reform in Germany. The Social Code Book V (§ 87a Sec 4 No 3) requires the collective contracting partners to determine risk adjusted payment targets for regional populations thereby also taking into account shifts between inpatient and ambulatory care.
Using predictive modelling patient groups are identified which meet the following two criteria in two consecutive years: 1) increases in actual cost exceeded expected cost in sector a while expected cost exceeded actual cost in sector b; 2) absolute number of cases increased in sector a and decreased in sector b. The model is based on the definition of a limited set of risk groups as defined by the risk adjustment scheme applied to German sickness funds. For our study these risk groups have been calibrated separately for each sector creating a common set of predictors. The second criterion focuses the approach on patient shifting as the most tangible effect of shifted care. In order to quantify the effect of patient shifting another predictive modelling approach is developed using the difference between expected and actual inpatient cases per risk group to estimate the resulting change in ambulatory case load. The cost of the additional case load per risk group is calculated for Germany based on population-based claims data (77 million patients).
The criteria for patient shifting as defined above apply to 26 out of 95 risk groups. At the level of risk groups hardly any patient shifting into ambulatory care was detected. On average for each patient with the respective risk factors 0.6 additional cases in ambulatory care were estimated as result of reduced incidence of inpatient care. In total the additional cost associated with patient shifting from inpatient care to ambulatory care was estimated 424 million € (2007). This represents 1.5% of total spending on ambulatory care and underlines the importance of the issue to health services research. Roughly 80% of this amount is likely to be eligible to physician services relevant to morbidity adjusted targets under payment reform. Prior to implementation as a payment formula, however, the approach needs to be based on a comprehensive risk adjustment model and needs further refinement.
住院护理与门诊护理之间医疗分工的长期变化所涉及的财务层面尚未得到系统监测。虽然这对卫生系统研究具有普遍意义，但目前迫切需要开发可靠的方法来衡量护理转移的影响，这是德国医生薪酬改革的一部分。《社会法典》第五卷（第87a条第4款第3项）要求集体签约伙伴为地区人口确定风险调整后的支付目标，从而也要考虑到住院护理和门诊护理之间的转移。
使用预测模型确定在连续两年内符合以下两个标准的患者群体：1）在a部门实际成本的增加超过预期成本，而在b部门预期成本超过实际成本；2）a部门病例绝对数增加，b部门病例绝对数减少。该模型基于应用于德国疾病基金的风险调整方案所定义的一组有限风险组。对于我们的研究，这些风险组已针对每个部门分别进行校准，从而创建一组共同的预测指标。第二个标准将该方法聚焦于患者转移，这是护理转移最切实的影响。为了量化患者转移的影响，开发了另一种预测模型方法，利用每个风险组预期住院病例与实际住院病例之间的差异来估计门诊病例量的相应变化。根据基于人群的理赔数据（7700万患者）计算德国每个风险组额外病例量的成本。
上述患者转移标准适用于95个风险组中的26个。在风险组层面，几乎未检测到任何患者向门诊护理转移。平均而言，对于具有相应风险因素的每位患者，由于住院护理发病率降低，估计门诊护理会增加0.6例。总体而言，从住院护理转移到门诊护理的患者所产生的额外成本估计为4.24亿欧元（2007年）。这占门诊护理总支出的1.5%，凸显了该问题对卫生服务研究的重要性。在支付改革中，这笔金额的大约80%可能符合与发病率调整目标相关的医生服务资格。然而，在作为支付公式实施之前，该方法需要基于一个全面的风险调整模型，并且需要进一步完善。
