Here you find everything you need to know to identify the cost of a specific treatment and use of a medical device in Germany.
Treatment costs in outpatient care
The price of drugs that are provided in the outpatient setting can be identified in the Lauer Taxe.
However, patients are not only treated with drugs but also receive other treatments and care, such as GP consultations, physiotherapy, psychotherapy etc. How are these treatment costs calculated in Germany?
Costs for SH-insured patients – Einheitlicher Bewertungsmaßstab (EBM)
The treatment costs for these care services offered in the German outpatient sector are set by the “Uniform value scale” (German: “Einheitlicher Bewertungsmaßstab (EBM)“). This directory details all outpatient services that are reimbursed by the SHI funds. All clinicians of SH-insured patients across all of Germany have to follow it and charge according to the EBM.
The EBM is determined by the Evaluation Committee of Clinicians (German: “Bewertungsausschuss Ärzte”), which includes members of the KBV and the GKV-SV.
For decisions on the EBM concerning services delivered in outpatient specialist care, i.e. those that can be delivered by clinicians or hospitals, the Evaluation Committee of Clinicians is joined by the German hospital association.
When the G-BA introduces new services into German outpatient care, the Evaluation Committee also decides on their remuneration.
The EBM database
The description of each service is quite detailed. It specifies exactly what needs to be provided and even how often it can be charged per case. The costs of services are expressed in points rather than monetary amounts. Only the costs of materials are provided directly in monetary terms. The actual amount to be paid is calculated by multiplying the points with a regional point value. The regional euro fee schedule is based on a national orientation value (German: “Orientierungswert”) in cents. In turn, the orientation value is adapted for the different regions and updated every year. For ease of use, the latest version of the EBM displays both the points and the monetary amount based on the orientation value.
A similar directory, the BEMA, is also available for dentists.
Reference: https://institut-ba.de/ba.html
Costs for privately insured patients – GOÄ
While the EBM lists all services and their costs for outpatient care for patients with SHI, the services for patients with private insurance can be found in the GOÄ.
The GOÄ separates the outpatient services into
- basic services (e.g. consultations and examinations),
- non-department-related special services (e.g. applying bandages and taking blood) and
- department-specific services (e.g. surgical treatments or laboratory medicine).
It is developed by the government, in collaboration with the German Association of Clinicians (BÄK) and the Association of PKVs. The GOÄ is not updated very regularly, and the latest amendment was made in 2019. Indeed, the costs in the GOÄ are still listed in the currency “Deutsche Mark”. To help users, this website, amongst others, has calculated the respective values in euro (please note that it is not legally binding though).
The GOZ is the respective directory for dentist services.
References:
Treatment costs in inpatient care
The G-DRG
The G-DRG determines the costs of hospital treatments of all patients, i.e. both, patients with SHI or with private health insurance.
Like in other countries, inpatient care costs are based on the DRG system. The German DRG, or G-DRG, dictates a flat rate by diagnosis for each admitted case. Obviously, every patient admitted to the hospital is different. Some have a more severe condition, others might need some additional services or a different amount of care. However, for every patient with the same diagnosis, the hospital will receive the same flat fee. While it might not exactly cover the costs incurred for every single patient, the G-DRG is aimed to offer fair compensation across all treated patients.
All German hospitals have to use the G-DRG to charge for their services. The exceptions are departments and clinics for psychiatry, psychosomatic and psychotherapeutic medicine, which are using the PEPP fee system (see below).
The G-DRG is developed by the InEK and is updated every year. It included all services and procedures provided by hospitals sorted by diagnosis and their associated costs as flat fees. It is based on data provided by hospitals that agreed to participate in the DRG calculations.
G-DRG codes
The hospital assigns their patients to a DRG based on their major and treatment-relevant secondary diagnoses (ICD-10-GM code) as well as the performed procedures (OPS code).
The information can be reviewed in the G-DRG browser. Each G-DRG code has 4 digits:
- 1. Digit: Chapter, based on Major Diagnostic Category (MDC) according to organ system,
- 2. and 3. Digit: Type of treatment, the numbers indicate e.g. whether it is a surgical, or non-surgical but invasive treatment, or a purely medical treatment without intervention,
- 4. Digit: This letter indicates the (economic) severity, with A incurring the most effort and therefore costs.
In addition to this code, each DRG is assigned a relative weight (German: “Bewertungsrelation”), which reflects the cost differences between different DRGs.
Costs in the G-DRG
The actual cost value for each DRG is calculated by multiplying the relative weight of the DRG with the base case value (German: “Basisfallwert”). There is a specific base case value for each of the 16 federal states in Germany. This guarantees that the costs are the same across all hospitals within one federal state. The value is updated every year.
The G-DRG also accounts for extreme cases. The DRGs indicate the time range patients within that DRG would stay in hospital. If a patient is in hospital for a shorter duration than the lower threshold, there will be a deduction. On the other hand, if a patient is staying longer than the higher threshold, there will be a surcharge.
Reference: https://www.g-drg.de/
Drug and medical device costs in the G-DRG
This flat G-DRG fee also includes the costs for drugs and medical devices. Therefore, when a new innovative (and likely costly) drug is introduced in German hospital care, the existing G-DRG often does not cover these additional costs. This means hospitals would not be sufficiently compensated. In order for hospitals to still offer the new treatment, they can apply for “Additional funds” (German: “Zusatzentgelte”), until the G-DRG is updated to reflect the new drug or device.
The PEPP fee system
Since 2018, hospitals have to use the PEPP system as a basis of their costs for services in psychiatry, psychosomatic and psychotherapeutic medicine.
Like the G-DRG, the InEK is responsible for developing the PEPP. To this end, they consult the GKV-SV, the Association of PKVs, and the DKG.
The PEPP system also is updated once a year based on data shared by participating hospitals.