§ 116 b SGB V – Chancen-Risiken-Analyse einer neuromuskulären Spezialambulanz

BACKGROUND The health care of patients with rare neuromuscular diseases needs to be improved. The novel German legal directive according to paragraph 116b of the Social Security Code V (§ 116 b SGB V) was a first step for reimbursement in regard to rare diseases which could possibly encourage specialised ambulatory clinical institutions to provide ambulatory care for patients suffering from rare diseases. Particularly, the implementation of „Einheitlicher Bewertungsmasstab” (EBM) should resolve the previous financial shortages. METHODS Costs and profits were calculated for six groups of neuromuscular diseases characterised by homogenous medical needs. For all groups a standardised service package was defined and priced with different fee catalogues. In detail, the „Deutsche Krankenhausgesellschaft Normaltarif” (DKG-NT) and internal service charges (ILV) of the University Hospital of Erlangen were applied. To calculate the profits, the so-called flat charge according to § 117 was compared with the EBM. RESULTS The service packages and accordingly the costs for the different groups are heterogeneous. Neither the previous calculation base for reimbursement nor the recent one are cost-covering. To take advantage of § 116 b the frequency of outpatient treatments has to be restricted, in the presented analysis after 7 treatments the new model is at a disadvantage. CONCLUSION § 116 b was enacted to improve the care for patients suffering from rare diseases. This was achieved only partially. Compared to the model which uses the flat charge according to § 117, the model using the EBM has economic advantages only when the number of ambulatory treatments is severely restricted, but is not yet cost-covering. To improve the health care of patients suffering from neuromuscular diseases further efforts are required.