Outpatient case rates

Although CSS is generally in favour of flat rate compensation for individual outpatient services and procedures, it opposes zero night DRGs. The main point of criticism is that, at present, the proposed flat rates for certain outpatient hospital services can only be calculated on the basis of inpatient services. However, it is essential for this calculation to be based on outpatient data (sourced both from hospitals AND medical practices). Calculating these rates on the basis of inpatient service and cost data contravenes the Federal Health Insurance Act (KVG Art. 43 para.4; KVV Art. 59c) as it does not reflect the actual outpatient service and cost structure. Where there is no suitable outpatient service and cost data available for developing a tariff structure, then such a basis must first be created. It is further intended to restrict the use of flat rates to outpatient treatment in hospitals. This would create new interfaces and lead to unfair differences in the amounts paid for outpatient treatment depending on whether it was administered in hospital or in a doctor’s practice. This situation would not only go against the principle of cost-effectiveness, it would also run contrary to the idea of “the same rates for the same services regardless of where they are provided” and create new false incentives. That is why outpatient case rates must apply to the entire spectrum of outpatient service provision.

Outpatient case rates play a prominent role in the public discussion due to the first package of measures, i.e. the proposal to enshrine national flat-rate structures in law and set up a tariff organisation for outpatient care (see position on outpatient tariff organisation OAAT). A wide variety of contractually agreed outpatient case rates currently exist alongside Tarmed and are a functioning reality. The newly founded OAAT AG and its partners aim to jointly submit TARDOC and an outpatient case-rate structure to the Federal Council by the end of 2023 at the latest. Once the initial versions of each have been approved, the tariff structures will be further developed within OAAT AG.
It is questionable whether the submission of outpatient case rates that are ready for approval can actually be achieved by the end of 2023. After a first version of the case rates was submitted to the FOPH for review in December 2021, the FOPH report of August 2022 revealed substantial shortcomings and noted that the case rates were not yet ready for approval as they stood. If the FOPH sets the bar as high as it did for TARDOC when reviewing the formal application for approval, then the outpatient case rates still have a long way to go: completing the application, including coming up with a mutually acceptable cost-neutrality concept (coordinated with the TARDOC concept), and the subsequent FOPH review process will take at least six months. The tariff partners will then have to make corrections before submitting the application again. In particular, there is not enough time to remedy the weak point of insufficient underlying data if a proposal is to be submitted for approval by the end of June 2023. The fact that the FMCH has left the project must also be taken into account. Getting the doctors back on board to ensure appropriate representation for the next project phases will be challenging. Expecting the Federal Council to grant approval by the end of November 2023, i.e. within four months, so that the new system can be introduced on 1 January 2025 is hardly realistic. Therefore, it is important to ensure that the two tariff structure projects TARDOC / outpatient case rates are not working to the same time scale.

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