Health care policy in Europe vs. European health care policy: -(excuse the german graphics) At the birth of the European Economic Community – with the Treaty of Rome in 1957 - a European health care policy was completely insignificant! A growing need of political action began when the single market and its four freedoms were established (free movement of goods, services, people and money). With the Treaties of Maastricht (1993) and Amsterdam (1999) the EU receives Community competence for health care topics for the first time (in order to guarantee a high standard of health protoction) In accordance with the principle of subsidiarity, the shaping of health care stays a national task as a basic competence. European health care is therefore characterised by diversity, competition and convergence. The European understanding of health care policy is Influencing health-relevant and health sustaining behaviour by information and education. Shaping of health-relevant conditions by improving working and housing conditions, increasing safe traffic, reducing environmental damage. Shaping of health care policy with regard to activities, resources and institutions that are aimed on the supply, distribution and financing of preventive, curative and rehabilitational services. Key tasks of health policy are: forming health care structures that guarantee an adequate supply of health care services and distributing the financal burden even.
Coining attribute of all systems is the existance of a social security model. There is a basic distinction between 3 systems. By name: bismark, beveride and semashko! Due to the latest east-extension of the EU 27 we have a pre-existance of any minor or major form of these 3 models. However, the result of this heterogenicity is only a superficial integration!
Let’s have a look at two different countries: Bulgaria and Germany. Bulgarias capital city is Sofia. Bulgaria has 7,6 million inhabitants, their main religion is Christianity. Bulgaria has about 110 thousand square kilometres. The currency is the Lew. The BIP per inhabitant in 2008 was 8.856 USD, mean temperature in november is 8.6 degree. What’s about Germany? Our capital city is Berlin. We have more than 82 million inhabitants, our main religion is also Christianity. Germany has an area of round about 360 thousand square kilometres. Since the 1st of January 2001 our currency is the Euro. The BIP per inhabitant in 2008 was 34.212 USD, mean temperature in november is 2.4 degree. These are differences between european countries. But what is the common ground? We have the same problem! Organ shortage.
Finances are deaply impacted by the legal regulations of a county. Below the european directive we have several regulations in germany.
Major regulations in Germany are based on the TPG. The TPG passed the german Bundestag already 14 years ago (in 1997). The reasons for making a law were: People thought society wanted a predictability of legal decisions, Transplantation should be assigned as „routine“ patient care, Quantity of Organ donation should be improved and transperancy should be achieved in order to prevent organ trade.
Therefore 3 different task controls were implemented. Transplant centers were assigned for the waiting lists, organ harvesting and transplantation An allocation agency was assigned for bundeling patient data to create a „single“ waiting list and for organ allocation due to National and federal regulations. A Coordination agecy was assigned as a whole german Organ Procurement Organisation recieving all the data from the donor hospital and Organising the whole process of donation after brain death.
Now we are comming to the finances in detail! The health insurance of the organ recipient pays for everythink. the budeting systematic was created in analogy to the task crontrols by law as mentioned before. Corresponding contracts between different institutions had been signed. Yous see al the paragraphs in the diagram. Retrieval coasts were refundet as lump sum, Costs of donor hospitals were refunded by the DSO as a flat rate Registration is refundet as a lump sum The compensation of the organ transplantation itself is done with DRGs – diagnosis related groups. Which cover all treantments within hospital exept psycatrie
Rate of exchange: 1 Euro is 1,4 USD
You see the huge differences in the sum, Minimum charge is 18. thousand Euro for an uncomplicated kidney transplantation And for the upper end: Medical complications can help….!
Some facts: The DSO – the German foundation for Organ Transplantation - is a Non for Profit Organisation And works as the National Organ Procurement Organisation (§ 11 TPG) The work is based on Contracts between DSO and the central associations of the health insurance funds, the German Medical Association, the German Hospital Federation Here you see our structure, donor regions - each with associated TPZ, donor hospital DSO staff and offices. Another specifity is the heterogenicity of retieval staff (more than 700 surgeons)
Comparable allowance systems are applied for thoracic surgeon and other medical staff involved procured by the DSO
The total budget sum is divided by 4.275 transplantations. DSO receives 1.137 € per transplanted organ (in 2011) Balancing the number of cases = 100 % (ex-post adjustment). Proceeds higher than costs = DSO pays back the balance due, Costs higher than proceeds = DSO receives balance due
DSO and its contracts partners (Federal Council, Head Association of the German health insurers, German Hospital) have entrusted the Institute for the Hospital Remuneration System (InEK) to evaluate the lump sums for reimbursement on a yearly basis (determination of effective costs by sampling). All processes from the point of diagnosis of brain death until the end of organ removal are currently recalculated. The yearly amount of „Euros“ in the G-DRG-Systems is calculated on basis of efforts and costs of a random sample of hospitals. Budget 2012: the lump sums of reimbursement of costs to donor hospitals will be reevaluated based on the results of the InEK recalculation. DRG-Fallpauschalen Die Kostendaten werden dabei im Rahmen eines Ist-Kosten-Ansatzes auf Vollkostenbasis anhand der Vorschriften des Kalkulationshandbuches in den an der Kalkulation teilnehmenden Krankenhäusern einheitlich ermittelt.
14 hospitals participated in the initial calculation, 4 of them university hospitals. The participating hospitals reported 152 cases. Thus, 11 cases per were calculated on average per hospital. 70 per cent of the total volume of costs are for anesthesia and operation costs. Varying service at organ recovery. (Attempted) heart removals 35 % of the cases with coronary angiography and additional cardiac diagnosis.
Nils Fruhauf - Germany - Monday 28 - Financing the Donation and Transplantation Process
Financing of Organ Donation and Transplantation in Europe: The German System Nils R. Frühauf, Thomas Beck and Thomas La Rocca 11th Congress of the ISODP - November 27-30, 2011- Buenos Aires
Classification of social security in the EU Bismarck System Beveridge System Semashko System <ul><li>contribute balanced by salary and wages </li></ul><ul><li>principle of payment in kind and </li></ul><ul><li>cost-refunds </li></ul><ul><li>option for additional insurance </li></ul><ul><li>state budget / </li></ul><ul><li>tax factoring </li></ul><ul><li>payment of kind provided by national health offerer </li></ul><ul><li>option for additional insurance </li></ul><ul><li>state budget </li></ul><ul><li>payment of kind provided by national health offerer </li></ul><ul><li>no further insurance possible </li></ul>
EU vs. member state responsibility Art. 152 (5) EGV / 168 AEUV: „… responsibility remains of the single member state ….!?“ Mitgliedstaaten für die EU Agenda* for heathcare R&D , reforming information transfer Control of epidemics HIV prevention Pandemia planning Improving health conditions e.g.German responsibility Gesundheitsfonds Praxisgebühr DRGs EBM PKV Composite-responsibility Pharmaceutical approval and research R&D rare disease * 2003 – 2008: EU financing the topic with 353 Mio. Euro All about money…..?
Regulations on Transplantation <ul><li>EU-Directive </li></ul><ul><li>National Transplantat Law (TPG) </li></ul><ul><li>SGB V </li></ul><ul><li>Federal Transplant Law </li></ul><ul><li>Guidelines of GMA (BÄK) </li></ul>
Transplantationsgesetz (TPG) <ul><li>TPG 1997 German Bundestag, aims: </li></ul><ul><ul><li>Predictability of legal decisions </li></ul></ul><ul><ul><li>Assignment of transplant-medicine in patient care </li></ul></ul><ul><ul><li>Increase organ donation </li></ul></ul><ul><ul><li>transparency </li></ul></ul><ul><ul><li>prevention of organ trade </li></ul></ul>
Task control according to TPG Transplant centers waiting lists organ harvesting organ transplantation Allocation Stiftung Eurotransplant Leiden / The Netherlands Coordination of organ donation Deutsche Stiftung Organtransplantation since June 2000 Eurotransplant DSO TX-Zentren
Finances in Organ Donation and Transplantation Health insurance company of the organ-recipient Lump sum per Tx registration-lump sum organ removal (DSO) § 11 TPG DRGs donor-hospital organ allocation (ET) § 12 TPG refund organ transplantation (TPZ) § 10 TPG
§ 10 (TPG): Transplant centers <ul><ul><li>Transplantat centers obligations (examples): </li></ul></ul><ul><ul><li>Waiting list administration </li></ul></ul><ul><ul><li>Organ transplantation and documentation </li></ul></ul><ul><ul><li>Follow up of recipients </li></ul></ul><ul><li>„ Bundesbasisfallwert“ 2011 (theoretischer Wert): 2.963,82 € </li></ul><ul><li>upper corridor 2011: 3.037,91 € </li></ul><ul><li>lower corridor 2011: 2.926,77 € </li></ul>Finance of Tx as DRG - Fallpauschalen
DRGs in Transplantation 2011 DRG Bezeichnung Mittlere Verweildauer Bewertung Preis bei BBFW A01A Lebertransplantation mit Beatmung > 179 Stunden 58 31,636 93.763,41 € A01B Lebertransplantation mit Beatmung > 59 und < 180 Stunden oder mit Transplantatabstoßung oder mit kombinierter Nierentransplantation 34,7 15,545 46.072,58 € A01C Lebertransplantation ohne Beatmung > 59 Stunden, ohne Transplantatabstoßung, ohne kombinierte Nierentransplantation 26,9 11,898 35.263,53 € A02Z Transplantation von Niere und Pankreas 26,8 10,197 30.222,07 € A03A Lungentransplantation mit Beatmung > 179 Stunden 72,5 45,397 134.548,54 € A03B Lungentransplantation ohne Beatmung > 179 Stunden 27 14,008 41.517,19 € A05A Herztransplantation mit Beatmung > 179 Stunden oder Alter < 16 Jahre 76,3 47,802 141.676,52 € A05B Herztransplantation ohne Beatmung > 179 Stunden, Alter > 15 Jahre 61,2 22,655 67.145,34 € A17A Nierentransplantation mit postoperativem Versagen des Nierentransplantates oder Alter < 16 Jahre oder AB0-inkompatible Transplantation 25,1 8,274 24.522,65 € A17B Nierentransplantation ohne postoperatives Versagen des Nierentransplantates, Alter > 15 Jahre oder ohne AB0-inkompatible Transplantation 18,4 6,279 18.609,83 € A18Z Beatmung > 999 Stunden und Transplantation von Leber, Lunge, Herz und Knochenmark oder Stammzelltransfusion 110,4 72,926 216.139,54 €
<ul><ul><li>ET Budget is negotiated yearly </li></ul></ul><ul><ul><li>Consists of a basis budget for financing cross border tasks plus country budget for member state specific tasks </li></ul></ul><ul><ul><li>For every patient put on the waiting list a registration fee has to be paid which is related to the forecasted number of registrations </li></ul></ul><ul><ul><li>In 2011 registration flat rate 626 € per case, calculated on a basis of 6.724 registrations (total of 6.6 mio Euro, indexed for inflation & wage development) </li></ul></ul><ul><ul><li>) </li></ul></ul>§ 12 (TPG): Vermittlungsstelle Eurotransplant
<ul><li>Basic budget for basic mandate: </li></ul><ul><ul><li>Allocation services </li></ul></ul><ul><ul><li>Development of allocation </li></ul></ul><ul><ul><li>External networking </li></ul></ul><ul><ul><li>Reporting and accounting </li></ul></ul><ul><ul><li>Supportive services </li></ul></ul><ul><ul><ul><li>Clearinghouse function in case of cross border organ exchange etc. </li></ul></ul></ul><ul><li>Country specific budget: </li></ul><ul><ul><li>E.g. country specific allocation rules (LAS) </li></ul></ul><ul><ul><li>HU audits </li></ul></ul>§ 12 (TPG): Vermittlungsstelle Eurotransplant Basic Budget Country- specific Number of registrations for the different countries
Rostock Hamburg Marburg Homburg Erlangen Freiburg Berlin Hannover Leipzig Essen Mainz München Stuttgart DSO 7 regions 14 teams, 50 TPZ 1.346 donor Hospitals (ICU) Regional abd. team Headquarter Regional supply office Regional central office § 11 (TPG): Koordinierungsstelle DSO <ul><li>NORD </li></ul>NORDRHEIN- WESTFALEN BADEN- WÜRTTEMBERG BAYERN MITTE OST NORDOST
DSO: Budgeting systematics Organisational flat rate DSO does not recieve an entire budget sum but recieves a lump-compensation for every transplanted organ, negotiated yearly. In the year 2011, the organisational flat rate is 7.744 € per transplanted organ. 4.275 transplantations are assumed. DSO covers all costs theat occur during the donation process as well as structural costs with this flat. DSO has contracts with organ retrieval surgeons, neurologists, labs beside the own staff. Exeptions: refund of costs to the donor hospitals and flight costs for non-renal organs. Compensation mechanisms if the fixed number of cases is not reached or exeeded.
DSO: Allowances Surgeons <ul><li>Special cases: </li></ul><ul><li>Kidneys en bloc: 820,00 € </li></ul><ul><li>Split liver, if both splits are transplanted: 1.640,00 € </li></ul>Allowance for abdominal retrieval teams: 1 organ (individual kidney, liver or pancreas) € 820,00 2 organs € 1.640,00 3 organs € 2.460,00 4 organs € 3.280,00 5 organs € 4.100,00 If no organ has eventually been transplanted € 290,00
DSO : Air transport - extrarenal organs Air transport of extrarenal organs In 2011, the lump sum for an air transport of an extrarenal organ is 6.753 € per transplanted organ for which a separate flight is carried out. Unsuccessful operations are included in the lump sum and will noch be refunded separately. The lump sum is based on the assumption that 970 air transports will be carried out in 2011. If the number of 970 flights is exeeded 50 % of the additional proceeds will be refunded to payers. If the number of flights is lower than 970 flights 50 % of the lacking revenues will be refunded by the payers.
DSO : Air transport - extrarenal organs Establishing an air transport network responsible for the organisation of all national and international transports of organ retrieval teams and organs. <ul><li>Main goals and principles: </li></ul><ul><li>quality, safety and economic efficiency </li></ul><ul><li>medical necessities, CIT </li></ul><ul><li>consideration of transport distance </li></ul><ul><li>avoiding „empty“ flights </li></ul><ul><li>rare use of cost-intensive jets </li></ul><ul><li>trustworthy und competent partners </li></ul>
DSO: Reimbursement of costs to donor hospitals <ul><li>Every year, the contract partners agree on lump sums for the reimbursement of costs to donor hospitals. </li></ul><ul><li>Modular lump sums for each possible result of a donation process : discontinued before or during organ removal, actually performed donation) are paid out by DSO in order to cover the costs that incur in the donor hospital. </li></ul><ul><li>The reimbursement does not depend on the fact whether a transplantation is carried out or not! </li></ul>Actual trends in ownership of german hospitals…
DSO: Reimbursement of costs to donor hospitals Module Presumed number of cases Amount Discontinued while on intensive care unit due to refusal 601 213 € Discontinued while on intensive care unit prior to organ removal 48 1.351 € Discontinued during organ removal 20 2.226 € Single-organ recovery 161 2.226 € Multiple-organ recovery 1098 3.587 € Total budget 4.860.157 €
InEK Institute for the Hospital Remuneration System <ul><li>May 2001: The Head Association of the health insurers (Bund) , Association of Private health insurers and the German Hospital Federation found the Institute for the Hospital Rumuneration System as a private limited company (PLC). </li></ul><ul><li>Since 2007 the institute operates under the name InEK GmbH. </li></ul>The Institute supports the contractual partners of self-administration and their boards in implementing and continuously developing the German-Diagnosis Related Groups-System (§ 17b KHG)
<ul><li>Initial calculation by InEK </li></ul><ul><li>Case definition of post mortal organ donation </li></ul>DSO: Reimbursement of costs to donor hospitals
DSO: Reimbursement of costs to donor hospitals Spain MOD € 6.000 + pro OP € 1.500/h Module Calculated Costs Difference compared to 2011 Discontinued while on intensive care unit due to refusal 259 € + 22 % Discontinued while on intensive care unit prior to organ removal 795 € - 41 % Discontinued during organ removal 2.907 € + 31 % Single-organ recovery 2.907 € + 31 % Multiple-organ recovery 3.679 € plus 200 € for additional instrumental diagnostic procedures + 3 % Total increase + 10 %
OCS Organ Care System <ul><li>Challenge: Financing the OCS™ </li></ul><ul><li>Disposible costs </li></ul><ul><li>The recipient‘s health insurance pays a flat rate of 43.881,00 Euro per transplanted heart to DSO </li></ul><ul><li>in addition to organisational and air transport flat rates. </li></ul><ul><li>Benefit for the patient has to be proven.... </li></ul>
Summary: organ donation/transplantation <ul><li>Each EU member state has own regulations – role of the EU </li></ul><ul><li>Impact of the German Transplant law </li></ul><ul><li>Payments of Insurance company of the recipient, organ transplantation as G-DRGs. </li></ul><ul><li>Efforts for allocation, registration flat for ET </li></ul><ul><li>Efforts of the donor hospitals due to organ donation, payback through DSO (flat) </li></ul><ul><li>Transport and retrieval, organisational flatrate for DSO </li></ul><ul><li>Challenge: eg new preservation methods (OCS) </li></ul><ul><li>PRINCEPLE: Transparency and no financial incentives </li></ul>