Inpatient Dialysis in Germany - Financing and Economic Challenges

IntroductionChanges in the German hospital financing system with fixed revenues, an aging population as well as an increase in the volume of patients showing multi-morbid chronic conditions cause new challenges for all health service providers. Especially in the field of kidney diseases and the need of renal replacement therapies those changes are of particular importance. Several studies have shown that the prevalence as well as the average age of patients have increased during past years (Frei et al., 2008, pp. 29-37). Furthermore, it could be shown that personnel time spent on medical service provision and nursing depends on diverse process options during a dialysis treatment (Krohn, 2014, pp. 59-80). All these factors affect the cost of medical treatments. Due to fixed revenues it is obvious that most health service providers and decision makers focus on the cost, mainly with regard to improvements in process management. However, these improvement activities seem to be limited in the long run. Cost covering and consequently sustainable provision of service can only be possible if the financing of these services can cope with the arising challenges. The identified challenges are not unique to the German hospital financing system. They can also exist in further lump-sum-based financing systems like the one in Australia (Department of Health, 2014, pp. 28-29), the United States of America (CFR, 2015, §402.104), the United Kingdom (NHS England, 2014, pp. 17-24) and France (Busse et al., 2011, p. 54). Due to different legal regulations and because of a low share of inpatient dialysis in comparison to outpatient treatments the number of economic analyses is rather limited. Existing studies mainly focus on single treatments or annual costs. Thus, a discussion of revenues per lump-payment based on the options given by legal regulation seems to be inevitable.The purpose of this article is to show various financing options for inpatient dialysis, to analyze the average revenue per dialysis and to state and discuss economic challenges of these financing options from the providers' perspective.1.Financing aspects of dialysis treatmentsThere are numerous options of financing dialysis treatments in the German health care system. The following analysis focused on inpatient dialysis at a hospital with a dialysis unit. These hospitals mainly can bill dialysis services as additional charges beside the DRG lump sum payment or directly as part of the DRG.The first and more relevant option are national equal additional charges. These are billed in case of hospital treatment where renal failure is not the principal diagnosis.Example: A patient with chronic end stage kidney disease gets admitted to the hospital because of another medical condition, e. g. a revision or replacement of the hip joint with an average time of hospitalization of 15.7 days. So the assumed DRG I05A "revision or replacement of the hip joint without complicating diagnoses, .does not include the needed dialysis treatments during these time. The dialysis treatments are compensated by billing the additional charge several times - one additional charge for each dialysis.In case of inpatient intermittent dialysis three additional charges are predominant. The main additional charges are ZE01.01 (hemodialysis, intermittent, age over 14 years), ZE02 (hemodiafiltration, intermittent) and ZE62 (hemofiltration, intermittent). Furthermore, other intermittent dialysis methods and continuous dialysis can be billed by defined additional charges. Table 1 provides information on possible treatments at the dialysis unit. Each treatment is defined in the German Procedure Classification (German: OPS - Operations- und Prozedurenschlussel). In case of intermittent treatments the symbol "?" - normally defined by numbers - differentiates between type of anticoagulation (without, heparin, other (including citrate)) and duration of treatment (4-5 hours or extended up to 6 hours). …