A reform threatens psychiatric care
How to compensate psychiatric care?
Germany implements a new payment system for in-patient psychiatric care that psychiatrists fear will be detrimental to severely ill patients.
“In recent years no other country has implemented such a comprehensive payment reform in psychiatric care as Germany”, emphasises Alexander Geissler, expert on health-care management at the Technical University of Berlin. But what health-care economists view with some pride has driven clinical psychiatrists to the barricades. Psychiatrists and the health insurance companies tried to come to an agreement on the structure of the new system, known as PEPP (Consolidated Payment System for Psychiatry and Psychosomatics). Yet in October, 2012, the negotiations collapsed. Subsequently, against the demands of the clinicians, the German Minister of Health went ahead and implemented the reform.
Up until now, a psychiatric clinic was compensated every day for each patient, regardless of the severity of the sickness and the complexity of the treatment. In the new system, the payment will also be influenced by the diagnosis and the treatment effort. For instance, roughly calculated, the reimbursement for 14 days of treatment for a patient with an acute psychosis could be 8% higher than that of a patient being treated for anxiety disorder. The reform is intended to make the care more performance-based and more transparent. The system should show which clinics are treating the most severely ill patients, leading to a redistribution of funds between clinics. “At first nobody is going to like it”, Bernd Beyrle, head of the Department of Inpatient Care at Techniker Health Insurance in Hamburg, explains. “At this juncture no one knows who will come out ahead financially.”
But psychiatrists, at least, are sure who will not benefit in the end. Sebastian Stierl, medical director at the Lüneburg Psychiatric Clinic, says, “I’m afraid that the administration is not attempting to improve psychiatric care. Rather, they have set up a control mechanism to help lower costs.” Some clinics already have a personnel shortfall of up to 20%, and patients must all too often go back for more clinical care. Stierl stresses that: “The new system has done nothing to change the situation. Instead, they have set up fiscal incentives to treat less severely ill patients.”
This view comes from the fact that the new system contains discrepancies. The calculation for the new rates is based on an analysis done by the Institute for Hospital Reimbursement (InEK). For its database, the institute evaluated 17% of the cases in psychiatric and psychosomatic clinics. Psychiatrists argue that the InEK’s calculations are inadequate.
Peter Kruckenberg is a psychiatrist and chair of the Association for the Support of the Mentally Ill. He says: “Against the advice of the experts, the InEK has calculated the range of treatments primarily in 25-minute allotments.”
For patients with severe illnesses such as psychosis, a 25-minute therapy is often not feasible, and psychiatrists complain that there are other treatment costs that the InEK has failed to include. According to the new system, a clinic treating a patient with psychosis will receive less money after day 16, but reimbursement for a patient with depression, treated primarily psychotherapeutically, will stay the same. Thus, after a 30-day stay, a patient with depression will begin to bring in more money for a clinic than a patient with psychosis. Psychiatrists warn that this will cause psychiatric clinics to release seriously ill patients prematurely.
The government has reacted coolly to the psychiatrists‘ criticisms. They see the programme’s early stages as a learning platform. Clinics are expected to send back pertinent data early on so that readjustments can be made. After a multistage test period, the system will be fully implemented in 2022.
Clinic directors do not believe the readjustments will solve problems that they see as inherent to the basic concept of the new system. The Association of Psychiatric Clinic Directors has advised the clinics to refuse to participate in the initial test phase. However, health-care management expert Alexander Geissler warns: “Without the clinics‘ participation it will be impossible to improve the system.”
He and other observers of the German health-care reforms feel as if they have been transported 9 years into the past. In 2004, Germany introduced a flat-rate hospital payment system based on DRGs (Diagnosis-Related Groups) for physical illnesses. Instead of billing the number of days at a fixed rate per day, the costs are calculated at a fixed rate per operation or procedure. Apprehension over that change was as prevalent then as it is with the current one. Back then the new rules were also set into place against the wishes of the clinicians. In the meantime the DRG system has become well established and—discounting a few weak points—has proved to be successful. Perhaps the PEPP reform will also be regarded in a positive light in 10 years time.
This text appeared in the Lancet in February 2013.
Photocredit: Diana Kosaric / fotolia.de