Implications of the introduction of fixed reimbursement rates in Germany

The introduction of fixed reimbursement rates in Germany for cardiac surgery of adults, mainly coronary artery bypass grafting (CABG) and valve 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 in high-risk patients may result in financial losses for the operating institution. Furthermore, reports from the Society of Thoracic Surgeons national database indicate a trend over time towards a higher proportion of patients with adverse risk factors for the United States. To determine whether these trends are holding true for Germany, we conducted an analysis of the data from two institutions with the following questions: 1. Is there a trend over time towards unfavourable risk factors, and 2. Is there a relation between preoperative risk factors and postoperative length of stay? From 1987 to 1995, 3872 patients underwent CABG at the Departments of Cardiovascular Surgery of Justus-Liebig University Giessen and German Heart Center Munich. Medical history, preoperative condition, intra-, and postoperative course were recorded for these patients according to the protocol of the German quality assurance program. Preoperative condition of the patient was summarized with an additive risk score. The correlation between postoperative length of stay in the intensive care unit (ICU) and preoperative risk was investigated. 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 1987 and 1995 was observed. A close correlation between preoperative risk and postoperative length of stay in the ICU was found. A similar correlation existed between preoperative risk and actual costs of treatment. In addition, high-risk patients had a significantly higher likelihood of being discharged directly from our ICU to the ICU of other hospitals. Postoperatively, high-risk patients suffer more often from morbidity with subsequent prolonged intensive care and are, therefore, a financial burden for the operating institution in a reimbursement system with fixed rates. This is aggravated by the fact that a trend towards adverse risk profiles among patients undergoing cardiac surgery can be observed. Both factors combined may result in a scenario where those who would benefit most are denied surgical treatment.