Underdocumentation instead of underfunding

When a hospital is deeply in the red, there’s a frantic search not only for solutions but also for explanations.

Because when you have to explain to sponsors, supervisory boards, the media, and citizens that the local hospital is fighting for survival, all causes that lie outside the management’s responsibility are helpful. People then like to speak – rather vaguely – about the difficult health policy framework conditions.

And they use the scapegoat that always works: the diagnosis-related case rates (DRG). There are certainly things that could be questioned and improved in the DRG system. But it cannot be claimed that the case rates are generally not cost-covering. At the Institute for the Hospital Remuneration System (InEK) in Siegburg, great effort is made to accurately represent medical service provision. However, when you look at how services are documented in hospitals, it’s often completely absurd. According to the service documentation, 70 percent of patients over 65 treated in maximum care hospitals have no or only minor comorbidities or complications – even at a very advanced age. Despite a severity level of 0 and 1, they stay in the hospital for an average of more than seven days. This has nothing to do with reality, because of course, no one treats perfectly healthy people.

The paradox lies solely in the documentation and coding, which often does not take into account the important secondary diagnoses. Especially with regard to length of stay, the pressure that is felt on the wards is often self-inflicted. Particularly older patients often have several comorbidities and need longer to be able to leave the hospital again. If this is coded correctly, these costs are also covered in the DRG system.

We don’t have underfunding in Germany – we have underdocumentation.

And the error lies in the system: By using coding specialists, we have separated documentation from service provision. This was actually supposed to relieve doctors, but has mainly led to detailed knowledge about patients being lost in this process. Because no one can document everything so comprehensively on paper that one can code correctly – based solely on the file. As so often in life, it helps to talk to each other. If you bring doctors, coding and nursing staff, and depending on the case, for example, midwives or social service staff back to the table, the Case Mix Index increases and revenues grow. The effort is limited if you exchange regularly. Ideally, you meet twice a week and go through the cases together. Before starting, the necessary case rate knowledge should be conveyed in training sessions. Because this has not been part of medical or nursing education so far.

Once the homework is done, the Case Mix Index also improves. Increases of up to 15 percent are possible within a few months. A clinic we recently supervised has impressively demonstrated this. The good thing is: Those who increase revenues have to save less. This pleases employees, sponsors, supervisory boards, and the media alike. The DRG scapegoat can finally call it a day.