Healthcare systems around the world have undergone major reforms
to cut down their costs. Amir
Inbar of Mediclever describes alternative
reimbursement mechanisms in the German market.
In the first part of this series, Amir described G-DRG reimbursement and
outlined two less well known alternative mechanisms: NUB and Integrated
Care.
In this article, Amir details the required criteria to utilize each of
the alternative mechanisms, their submission process, and their benefits
and disadvantages.
|
| NUB Reimbursement |
Article 6.2 of the Hospital Remuneration Law (KHEntgG) enables hospitals to
submit requests for reimbursement of "new and innovative diagnosis and
treatment methods" that did not obtain a G-DRG code yet.
|
| NUB Required Criteria |
| To submit a NUB reimbursement request, the hospital should
fulfill the following criteria:
|
- The new and innovative method affects several existing G-DRGs.
- The new and innovative method can be clearly defined.
- The cost of using this new and innovative method affects the cost structure
of the relevant procedure and the overall cost structure of the hospital.
- The requesting hospital's financial situation would be worse if the request
is rejected.
|
| The NUB Application Process |
Any hospital interested in submitting a request for NUB
reimbursement should fill out a request form, which can be downloaded
from the InEK
site.
The
application must be submitted by October 31 and provide the following:
--information
regarding the substituted (old) method,
--date of first applying the new
method, and
--number of patients treated and expected number of patients that
will be treated according to this new and innovative method.
Furthermore,
a cost analysis comparing between the old and new methods should be added.
InEK
checks all submitted applications and assign a value of 1 to 4. Replies,
which includes the value, are received by for each application by January
31.
Value 1: The innovative method corresponds
with the requirements and will be reimbursed. Usually, InEK will not have a national database that enables a uniform
reimbursement rate, therefore each hospital and local GKV negotiation committee
will negotiate the reimbursement rate. InEK will also check if the innovative
method can be adapted into the G-DRG framework
Value 2: The innovative method does
not correspond with the requirements. The hospital is not allowed to negotiate reimbursement
with any sickness fund.
Value 3: InEK is overloaded and cannot reply to the
submitted application until the deadline of Jan 31. The hospital
may negotiate NUB reimbursement with interested sickness funds.
Value 4: The application was not clear or did not explain
clearly why NUB reimbursement is needed. The hospital may negotiate
NUB reimbursement with interested sickness funds.
|
| NUB Benefits & Disadvantages |
Benefits
Obtaining NUB reimbursement takes a relatively short time. This could
lead to immediate increase in procedure and sales volume.
There are no risks
in receiving a rejection and a negative reply will not affect chances of
obtaining another reimbursement mechanism in the future.
Disadvantages
NUB reimbursement only applies to submitting hospitals and requires bilateral
negotiations between each hospital and the local sickness funds.
Each agreement
is only valid for one year, but may be renewed, relatively easy, unless
it has become a part of the G-DRG system.
In recent research conducted
by the Institute of Health Economics (IFG), it was suggested that hospital
submissions will be available throughout the year and innovative methods
that received a value 1 reply will automatically be reimbursed until included
in G-DRG and apply to all relevant hospitals.
During 2006, 3,857 requests were submitted. Out of which, 1,498 requests
received a Value 1 reply for 54 new methods.
|
| Integrated Care Reimbursement |
Until recently
there was a strict division between in-patient and out-patient care in
Germany. This resulted in massive duplication of services and (diagnostic)
procedures, wasted resources, and lacked coordination
between in- and out-patient care. The concept of Integrated Care (IC) aims
to bridge the gap between ambulatory and hospital care.
IC Entities unite different types of healthcare providers (GPs, specialists,
labs, rehabilitation facilities, etc.) to facilitate Disease Management Programs
(DMPs). These IC entities are entitled to freely negotiate
reimbursement rates with the sickness funds. To provide a financial incentive to form these
entities, the German law allocates 1% of total annual reimbursement amount
towards IC projects.
|
| IC Required Criteria |
Formally, there are no preconditions, however, sickness funds
will require to understand how will the IC project improve patient care and
save overall costs.
|
There is no formal process, but some sickness funds
have downloadable request forms on their website. A typical application
should include --
--treated clinical indications, provided services and their location;
--expected number of treated patients;
--roles and responsibilities of managing entity; and
--benefits of the IC project in terms of patient care and cost savings.
|
| IC Benefits & Disadvantages |
Benefits
Setting up an IC project takes a relatively short
amount of time. As in the case of NUB, this could lead to immediate increase
in procedure and sales volume.
There are no inherent risks involved, and there are integrated financial
incentives for all participants.
Disadvantages
Local agreements requiring bilateral negotiations.
As of the beginning of
2006, more than 1,400 IC contracts were signed with a value of €375
million.
|
| Summary |
The German healthcare system is trying to cope with the built-in
delays of integrating innovative diagnostic and therapeutic treatments into
the system by facilitating different types of intermediate short-term reimbursement
mechanisms. Some of those mechanisms are described in this article. Utilizing
these mechanisms can help Israeli companies obtain reimbursement faster,
bring their products to market sooner, and increase their chances of obtaining
a G-DRG code at a later stage.
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About Mediclever
Mediclever
manages end-to-end reimbursement projects for Israeli companies selling medical
technology products in the United States and Europe.
Mediclever identifies the availability of existing reimbursement codes (relevant
to the product), and in case such existing mechanisms
do not exist, Mediclever outlines processes and criteria for obtaining coverage,
including the development of new or modified codes and the establishment of favorable
coverage guidelines for such codes.
Mediclever appoints an outsourced reimbursement project
manager for each Israeli client. The manager works at the client's site and leads
the leading the reimbursement project, which saves the company from
hiring and training a full-time reimbursement manager.
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