IMPLICATIONS OF THE INTRODUCTION OF FIXED REIMBURSEMENT RATES IN GERMANY

The introduction of fixed reimbursement rates in Germany for cardiac s urgery of adults, mainly coronary artery bypass grafting (CABG) and va lve surgery, has shifted the financial risk from insurers to providers of medical care, namely hospitals. Costs in turn are closely related to the preoperative condition of a patient, implicating that surgery i n high-risk patients may result in financial losses for the operating institution. Furthermore, reports from the Society of Thoracic Surgeon s national database indicate a trend over time towards a higher propor tion of patients with adverse risk factors for the United States. To d etermine whether these trends are holding true for Germany, we conduct ed an analysis of the data from two institutions with the following qu estions: 1. Is there a trend over time towards unfavourable risk facto rs, and 2. Is there a relation between preoperative risk factors and p ostoperative length of stay? From 1987 to 1995, 3872 patients underwen t CABG at the Departments of Cardiovascular Surgery of Justus-Liebig U niversity Giessen and German Heart Center Munich. Medical history, pre operative condition, intra-, and postoperative course were recorded fo r these patients according to the protocol of the German quality assur ance program. Preoperative condition of the patient was summarized wit h an additive risk score. The correlation between postoperative length of stay in the intensive care unit (ICU) and preoperative risk was in vestigated. For a subgroup of 30 patients, detailed cost analysis was performed and the relationship to preoperative risk examined. For all risk factors examined, a significant increase in prevalence between 19 87 and 1995 was observed. A close correlation between preoperative ris k and postoperative length of stay in the ICU was found. A similar cor relation existed between preoperative risk and actual costs of treatme nt. In addition, high-risk patients had a significantly higher likelih ood of being discharged directly from our ICU to the ICU of other hosp itals. Postoperatively, high-risk patients suffer more often from morb idity with subsequent prolonged intensive care and are, therefore, a f inancial burden for the operating institution in a reimbursement syste m with fixed rates. This is aggravated by the fact that a trend toward s adverse risk profiles among patients undergoing cardiac surgery can be observed. Both factors combined may result in a scenario where thos e who would benefit most are denied surgical treatment.