Abstract
Background: Debate is currently taking place over minimum case numbers for the care of premature infants and neonates in Germany. As a result of the Federal Joint Committee (Gemeinsamer Bundesauschuss, G-BA) guidelines for the quality of structures, processes, and results, requiring high levels of staffing resources, Level I perinatal centers are increasingly becoming the focus for health-economics questions, specifically, debating whether Level I structures are financially viable. Materials and Methods: Using a multistep contribution margin analysis, the operating results for the Obstetrics Section at the University Perinatal Center of Franconia (Universitäts-Perinatalzentrum Franken) were calculated for the year 2009. Costs arising per diagnosis-related group (DRG) (separated into variable costs and fixed costs) and the corresponding revenue generated were compared for 4,194 in-patients and neonates, as well as for 3,126 patients in the outpatient ultrasound and pregnancy clinics. Results: With a positive operating result of € 374,874.81, a Level I perinatal center on the whole initially appears to be financially viable, from the obstetrics point of view (excluding neonatology), with a high bed occupancy rate and a profitable case mix. By contrast, the costs of prenatal diagnostics, with a negative contribution margin II of € 50,313, cannot be covered. A total of 79.4% of DRG case numbers were distributed to five DRGs, all of which were associated with pregnancies and neonates with the lowest risk profiles. Conclusion: A Level I perinatal center is currently capable of covering its costs. However, the cost–revenue ratio is fragile due to the high requirements for staffing resources and numerous economic, social, and regional influencing factors.
- Perinatal centers
- Federal Joint Committee (Gemeinsamer Bundesauschuss, G-BA)
- financing
- staffing resources
- DRG
- contribution margin analysis
Highly specialized Level I perinatal centers in Germany, in particular, are increasingly becoming a focus for health-economic concerns. In view of current debates on minimum case numbers and the guidelines published by the Federal Joint Committee (Gemeinsamer Bundesauschuss, G-BA) for the quality of structures, processes, and results, with high requirements for material and staffing resources in care for high-risk pregnancies and premature infants and neonates, there is a need to clarify the actual funding of highly specialized obstetric services, in a period of increased competitive pressure and scarce resources in the diagnosis-related group (DRG) system (1).
The G-BA's multilevel approach, with corresponding quality requirements, for four hierarchically-structured levels of care (Level I–IV perinatal centers) has been in operation in German hospitals since January 1st, 2010 (2): Level I perinatal centers: care for premature infants and neonates with the highest level of risk; Level II perinatal centers: intermediate care provided as comprehensively as possible for premature infants and neonates with a high level of risk; Perinatal specialization (Level III perinatal center): comprehensive care for neonates in whom it is already foreseeable before birth that effective neonatal medicine will be needed; Obstetric Department (Level IV perinatal center): only full-term neonates, with no risk present.
Detailed catalogues for the required staffing and material structures and processes exist for all four of these levels. The health-insurance institutions are required to test whether these requirements are being met as part of the annual budget negotiations. According to the German Hospital Association (Deutsche Krankenhausgesellschaft, DKG), there are currently 272 perinatal centers at Levels I-IV in Germany. Due to collaborations between individual hospitals, this figure is higher than the actual number.
A regulation regarding minimum numbers of cases for perinatal centers was introduced for the first time on January 1st, 2010. Debate over minimum case numbers began following a press release issued by the Scientific Medical Specialist Societies Working Group (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF) in June 2007 stating that survival and complication rates for neonates had been found to be decisively dependent on the individual maternity hospital (3). For Level I perinatal centers, a minimum number of 14 neonates per annum with a birth weight of <1250 g applied up to December 31st, 2010. On 17 June, the G-BA took the decision to raise this minimum number to 30 with effect as of January 1st, 2011. On January 26th, 2011, 30 German hospitals were granted an emergency injunction and the newly-introduced minimum number was suspended (4). The injunction was upheld in a complaints procedure on December 21st, 2011 (5). The debate is, thus, not yet concluded, and further legal decisions are awaited.
For Level I perinatal centers, the G-BA sets particularly high qualitative and quantitative structural requirements that are associated with extremely high capacity provision costs for staffing resources and infrastructure. For example, the 24 h presence of medical and nursing staff has to be ensured in intensive-care wards and in the delivery area. In addition, a neonatologist and emergency neonatologist must be on call day and night. In obstetrics, a specialist has to be in the building at all times. In addition, a holder of a specialist qualification also has to be accessible and available at all times (on call 24 h a day for 365 days a year) (2). These staffing costs represent the majority of the total cost of in-patient care, amounting to just under 70% of the costs (6). In terms of infrastructure, wall-to-wall siting of the neonatal intensive-care ward, delivery area, and operating room is required. In addition, at least six intensive-care beds are stipulated (2). Substantial costs can therefore also arise due to the architectural measures needed.
In addition to meeting the G-BA requirements, each hospital also has to span the gap between the capacities provided and those actually used, since only constant resource availability, which creates substantial costs, can ensure that a wide range of services are provided in order to obtain revenue (7). However, the question arises of whether it is useful for an individual hospital to offer the whole range of services in order to reach the highest perinatal center level. Hospitals in Germany today are more than ever facing issues involving their continued ability to exist, in addition to medical issues. Dominating is the question of the financial viability of the services offered and capacities provided. Particularly due to the minimum case numbers agreement and the associated debate, far-reaching decisions need to be made in perinatal medicine regarding the offered services.
The aim of the present analysis was to compare actual costs and revenues in a Level I perinatal center using a multistep contribution margin analysis. This is independent of the calculations by the Institute of Hospital Remuneration (Institut für das Entgeltsystem im Krankenhaus, InEK), which under certain conditions may not reflect the real situation. In addition to showing underfinancing, the analysis provided here considers and discusses the operating results of a Level I perinatal center, the relative proportions of DRGs, the costs and revenue of the individual DRGs and special areas of responsibility, the individual services and their proportion of the total contribution margin, dependencies of services on each other, and the areas and services that are not independently financially viable.
Materials and Methods
Location of the survey used for the cost accounting model. The University Perinatal Center of Franconia (UPF) is one of the certified centers in the Department of Gynecology at Erlangen University Hospital, along with the University Breast Center of Franconia, the University Reproductive Medicine Center of Franconia, the University Gynecological Cancer Center of Franconia, and the University Endometriosis Center for Franconia. In 2009, the Department of Gynecology at Erlangen University Hospital treated 7,375 in-patient cases and carried out 977 outpatient operations, with a total of 4,414 operations overall and an average economic case mix index (CMI) of 0.765 for all patients.
The UPF represents the largest proportion of the case numbers for major diagnoses, procedures, and also numbers of DRGs (8).
Cost accounting model. A distinction is generally made between full-cost accounting systems and direct-cost accounting systems. Full-cost accounting is characterized by complete passing-on of all type of costs to the cost centers (separate organizational units in an enterprise in which costs arise) and finally to the individual cost bearers (9). The cost bearers are all operating services leading to usage of goods or services (e.g. DRGs). The main point of criticism of full-cost accounting is that costs are assigned to cost bearers that have not given rise to them. For this reason, this type of calculation is not appropriate for decision-making regarding short-term changes in service programs (10). A further problem is the arbitrary allocation of overheads and overproportionate or underproportionate charging of fixed costs (9).
A direct-cost accounting system, namely a multistep contribution margin analysis, was chosen for the present calculation. Like full-cost accounting systems, this also takes all costs into account, but only charges part of the costs directly to the cost bearers (11). Costs that cannot be distributed relative to cause are included in the calculation as a block (12). The most important feature here is the division of overall costs into employment-variable and fixed costs, with only the employment-variable costs being charged to the cost bearers (13). In variable costs, a distinction generally has to be made between variable costs for materials, variable costs for internal cost allocation (ICA), and amounts for DRG revenue distribution. Since hospital maintenance costs, for example, arise independently of the treatment of any specific patient, these costs are assigned as fixed costs. By contrast, costs for patient care depend on the number of hospital days and must therefore be classified as variable costs. Precise assignment of variable material costs to each patient has not been carried out; the increase in information obtained would not have justified the effort involved. Instead, costs have been distributed to the various DRGs using the allocation formulas “hospital days,” “patient clinical complexity level (PCCL) values” (on a scale of 0-4, estimated according to the complexity of the treatment, based on the severity of the principal and secondary diagnoses), “cases,” “surgery cases,” and “minutes of surgery.”
A contribution margin is the amount that is available to a hospital after the deduction of variable costs from the revenue required to cover fixed costs. In the multistep contribution margin analysis, the fixed-cost block is differentiated into several hierarchical levels (10) in order to obtain as good an overview as possible of the fixed-cost structure and the way in which the operating results arise (14). Typically, fixed costs in a hospital are classified as follows, for example: Classes of hospital cases (e.g. vaginal delivery using an episiotomy); Groups of case classes (e.g. vaginal deliveries); Wards (e.g. obstetric ward); Specialist departments (e.g. obstetrics); Hospital as a whole (9, 14).
For the reasons given above, the multistep contribution margin analysis is particularly appropriate for calculating the operating results on a direct-cost basis, for planning the optimal program of services, for break-even analyses (15), and for planning and control of profits and losses in separate business units (16). It is therefore also suitable for answering the questions raised here. In general, multistep contribution margin analysis is also the form of direct-cost accounting most frequently used in hospitals (17).
Only the parts of the UPF belong to the Department of Gynecology at Erlangen University Hospital were used to calculate the operating results for 2009, so as to provide an overview of obstetrics. Not included, by contrast, was the cost and revenue structure of the neonatology section, including the neonatal intensive-care ward, which belongs to the Department of Pediatrics at Erlangen University Hospital. In addition, the calculation only takes into account patients with public health insurance, in order to provide transparency and avoid cross-subsidies from bills for private health treatment.
Relevant costs centers at the UPF consisted of the obstetrics wards (two, with a total of 36 beds), the delivery room, the cesarean operating room, the outpatient ultrasound clinic (only for external prenatal diagnostic services, excluding gynecological diagnoses) and the outpatient pregnancy clinic.
The basis used for the calculation was a total cost report for the UPF classified according to cost types and cost centers, partly DRG-related. The data were extended by identifying surgical cases and surgical minutes from the Medical Control Center (MCC) and calculating real staffing costs, particularly using responsibility schedules and duty rosters, as well as structured interviews.
In the DRG system, the grouping process was carried out using age, sex, weight on admission, period of hospital stay, and reasons for admission and discharge. In addition, the severity of the disease was taken into account using PCCL values. Taking these resource usage characteristics into account made it possible to form homogeneous and thus comparable groups of patient cases (18). In the outpatient field, differentiated data collection was not possible. In the present model, revenue assignments here were based on the University outpatient flat rate per case (14).
The main purpose in developing a cost accounting model was to distinguish areas of responsibility and hierarchical levels from each other, allowing fixed costs to be treated as individual costs as far as possible. Since DRG services do not create any costs that are always and without exception directly attributable to one cost center, the costs centers for “obstetric wards,” “delivery room,” and “delivery room/surgery” had to be combined into a single large cost center to calculate contribution margin I at the DRG level. The two outpatient structures for ultrasound and prenatal/pregnancy services were separated from the above in-patient structures.
Table I shows the final cost accounting model. The results of this model made it possible to assess whether contribution margin I for the cost centers considered was sufficient to cover the fixed costs in each case. The resulting contribution margins II at the DRG level for outpatient ultrasound and for outpatient pregnancy services show whether in-patient or out-patient areas of the UPF in the current DRG system, together with the program of services offered, may or may not be financially viable. In a final step, the calculated contribution margins II are added together. The flat-rate administrative overhead costs borne by the Department of Gynecology at Erlangen University Hospital are then deducted from the resulting total. For the UPF, this amounted to 19.3% of revenue.
Results
Calculation of contribution margin I. The distribution of the fixed material costs by cost center showed the following result: obstetric wards (€ 125,171), delivery room (€ 68,986), delivery room/surgery (€ 2,505), and outpatient ultrasound (€ 4,653). The major items in these costs were cleaning of the buildings by outside firms (obstetric wards € 84,570, delivery room € 15,959, delivery room/surgery € 1,798), costs for maintenance of medical equipment (obstetric wards € 10,638, delivery room € 23,253, delivery room/surgery € 285), and maintenance or full servicing (obstetric wards € 5924, delivery room € 12,304, outpatient ultrasound € 917).
Table II shows the distribution of the DRG-relevant variable material costs according to the above allocation codes for the obstetric wards, delivery room, and delivery room/surgery cost centers. The highest variable material costs were generated in the delivery room, followed by the obstetric wards and, at a much lower cost, the delivery room/surgery. The € 701,141 of variable material costs for the DRG-relevant cost centers were mainly due to the following types of cost: garment rental (€ 113,434), drugs (€ 87,931), operating room materials (€ 87,880), medical and nursing consumables (€ 79,751), ward assistance supplied by external firms (€ 69,923), and centralized sterilization by external firms (€ 66,585).
The largest proportion of costs was distributed using the allocation code “hospital days.” The PCCL value was used for cost allocation in the cost types for medical and nursing consumables, for example, as well as for blood preparations and drugs, since patients with a large number of comorbid conditions and thus with more secondary diagnoses and a higher PCCL value inevitably also cause greater consumption of these resources. On the other hand, as the consumption of medical and nursing consumables, blood preparations, and drugs also increases with each additional hospital day, a split allocation code was also selected here and the costs were distributed to the DRGs at 50% for the number of hospital days and 50% for the relevant PCCL value. It was assumed here that costs per PCCL value increase to the same extent.
Overview of the final cost accounting model.
Distribution of diagnosis-related group (DRG) - relevant variable material costs (€).
Calculation of costs per unit of allocation coding.
Once all of the relevant allocation codes had been ascertained, the total for all units was determined for each allocation code. Dividing the total costs per allocation code by the sum of all units made it possible to define the costs per unit for each allocation code (Table III).
The coded variable costs for each DRG were then calculated. To do this, after the costs for each unit had been calculated, they had to be multiplied by the relevant units per DRG. Table IV gives an example of this procedure for DRG O60D.
To calculate contribution margin I per DRG, the coded variable material costs, the total ICA costs, and outflows from the DRG revenue apportionment were deducted from the total revenue (Table V). By contrast, inflows from the DRG revenue apportionment were added on. The average contribution margin I per DRG case was calculated by dividing each contribution margin I per DRG by the number of cases in the DRG concerned. Overall, the UPF had a contribution margin I of € 5,180,312.39 at the DRG level.
The variable material costs and ICA costs for each cost center were deducted from the revenue obtained when calculating contribution margin I for outpatient ultrasound and outpatient pregnancy services, in the same way as for calculations of contribution margin I at the DRG level. In 2009, a total of 6,908 ultrasound examinations were carried out in the outpatient ultrasound and prenatal clinic, 2,958 of which (42.82%) involved obstetric or prenatal medicine services. Out of these, 1,715 (24.83%) were in the outpatient area and thus relevant both for variable costs and for fixed costs. Staffing costs were allocated by time spent; 43.47% of staff working time in the outpatient ultrasound clinic was thus attributable to outpatient obstetric services (Table VI). On average, there were 1.64 visits per case at the Department of Gynecology in Erlangen University Hospital in 2009. There was thus a case number of 1,045 for the outpatient ultrasound clinic in 2009, which was treated as relevant for the present calculation. A University flat-rate charge of € 94 was remunerated for each treatment case in the outpatient ultrasound clinic, giving a total of € 98,230.
Calculation of coded variable costs per diagnosis-related group (DRG), based on the example of DRG O60D.
A total of 2,081 cases were treated in the outpatient pregnancy clinic in 2009 (with 4,296 visits). With a treatment flat-rate charge per case of € 94 per case, this corresponds to total revenue of € 195,614. Overall, after deduction of the relevant variable costs, there were contribution margins I of € 90,548 in the outpatient ultrasound clinic and € 147,931 in the outpatient pregnancy clinic.
Calculation of contribution margin II. Following the calculation of contribution margin I at the DRG level, in the outpatient ultrasound clinic, and in the outpatient pregnancy clinic, the material costs classified as fixed, the ICA costs classified as fixed, and also staffing costs for the three different cost centers in the cost accounting model had to be deducted from each contribution margin I in order to calculate contribution margin II. ICA costs at the DRG level totaling € 240,544 that were classified as fixed and not directly assignable to a DRG resulted in particular from catering services (€ 184,768), technical services (€ 23,430), the pharmacy (€ 15,808), and finally costs for pastoral care (€ 10,256).
The Department of Gynecology and Obstetrics at Erlangen University Hospital provides the UPF with 7.5 full-time posts for resident physicians, five full-time posts for senior physicians, and one full-time post with a management function. Staffing costs were thus calculated on the basis of average staffing costs for 2009 (Table VII). The proportions of physician costs per cost center were calculated using structured interviews and assessments of responsibility schedules and duty rosters.
Calculation of contribution margin I at the diagnosis-related group (DRG) level.
As the UPF is a perinatal center with an attached midwifery school, the midwifery students partly carried out the work of trained midwives. To take this into account, staffing costs for the delivery room were increased by a further three full-time midwifery staff members (Table VIII).
The outpatient pregnancy clinic was another special factor. With the exception of physicians, all staffing costs in the outpatient pregnancy clinic were calculated via the delivery room, based on a hospital-specific agreement. Further differentiation of further staffing costs in the outpatient pregnancy clinic did not provide any additional information.
A contribution margin II at the DRG level of € 1,614,439.64 was calculated after subtraction from contribution margin I of the ICA costs classified as fixed and of the relevant staffing costs. Contribution margin I from the outpatient ultrasound clinic was not sufficient to cover the fixed costs of this cost center, resulting in a negative contribution margin II of € 50,313. In contrast, a positive contribution margin II of € 81,535 was recorded for the outpatient pregnancy clinic.
Result of the cost accounting model. Table I provides an overview of the final UPF cost accounting model, with all of the relevant figures. To calculate the UPF's operating results for 2009, all contribution margin IIs first had to be summed. In the next step, from this total of € 1,645,661.64 the administrative overhead costs borne by the UPF, amounting to € 1,270,786.82, were subtracted from it. This amount represents 19.3% of all UPF revenue.
Allocation code for the outpatient ultrasound (OU) cost center.
Calculation of staffing costs for physicians.
Overall, the multistep contribution margin analysis for the UPF in 2009 thus showed, as contribution margin III, an initially positive operating result of € 374,874.81. The costs of the outpatient ultrasound clinic were not covered, with a negative contribution margin of € 50,313. A total of 79.4% of all cases at the UPF were due to DRGs P67D, O60D, O01F, O60C, and O65B, which are all associated with normal pregnancies and healthy neonates (Table V).
Discussion
During the past few decades, the survival threshold for premature infants has shifted to earlier and earlier gestational weeks. According to the current AWMF guideline, premature infants must in principle be treated from gestational week 24+0. In this area, a premature infant's chances of survival are in the range of 60-75% (19).
The numbers of surviving neonates can be used as a measure for assessing the cost-effectiveness of obstetric care structures. This allows a very high level of cost-effectiveness in perinatal centers, since a large number of life-years are gained in cases of survival, generally leading to numerous quality-adjusted life-years (QALYs) (1, 20, 21). However, the cost-effectiveness of highly specialized centers initially only exists from the point of view of society as a whole or the healthcare system; for the actual centers themselves, the focus is also on the additional costs of specialization in the framework of a center. Several studies have already shown that in the field of oncology, certified breast centers are currently producing negative operating results in the DRG system, or require additional charges for the highly specialized structures involved (22, 23). Using a stepwise fixed-cost contribution analysis, Wagner et al. (23) calculated the operating results for a certified breast center as an isolated unit. This showed that the breast center made an absolute loss of € 760,000.
The facilities available in today's perinatal medicine in particular thus raise the question in relation to perinatal centers, in accordance with the G-BA criteria, of whether their highly specialized structures and services are adequately remunerated (24). Due to the strict requirements which apply (2), perinatal centers involve a high level of resource consumption to provide the infrastructure in terms of staff, materials, and rooms. For this reason, the economic and business aspects of a hospital business are becoming increasingly important for obstetric departments at all levels of care provision in order to ensure their continued existence, in addition to medical, ethical, legal, and political considerations. In view of the requirements established by public health policy to constantly improve treatment results in obstetrics, it is first needed to examine whether any costs that remain uncovered at perinatal centers are inconsistent with these requirements. Only evidence of a financing deficit can provide a promising basis for successful negotiations (25). However, there are as yet no published cost accounting models for perinatal centers at the various levels. The present isolated global view of the cost and revenue situation at a Level I perinatal center provides a certain amount of transparency. With the multistep contribution margin analysis, the model initially showed a profit of € 374,874.81. This generally positive balance requires critical analysis, as it is dependent on various conditions.
Staffing costs at the University Perinatal Center of Franconia (UPF) in 2009.
Staffing resources. Due to legal requirements such as the discontinuation of on-call services, requirements for the availability of specialists and the constant background presence of the department head, the planning and control of staffing costs plays an important role in ensuring financial viability for perinatal centers in particular (26). The proportion of staffing costs as part of total costs for in-patient care amounts to approximately 70% (6). With a proportion of 55% of total costs, staffing costs at the DRG level – i.e. in the obstetrics wards, delivery room, and delivery room/surgery – may have been set too low in the present calculation (Table IX). If staffing costs at the DRG level were to increase to 70% of total costs (€ 4,123,125.29) and all other costs remained constant, the UPF would run at a loss of € 489,571.58.
Overview of the distribution of various cost types by cost center.
There are substantial differences in the staffing structures required at different levels (Table X) (27). In a report by Seelbach-Göbel (27), 21 full-time posts for physicians were considered necessary at a Level I perinatal center with approximately 2,000 births per year – a comparable institution. In the present calculation, the costs for physician staffing are based on only 7.5 full-time posts for resident physicians, five full-time posts for senior physicians, and one chief physician. In addition, a pediatrician post for delivery room/surgery was also included, so that only a total of 14.5 full-time posts for physicians was taken into account in the present calculation. If the costs for 6.5 more resident physicians were to be included (€ 442.871), the UPF would produce a negative operating result amounting to € −67,996.19. The reason why the system is able to function with a smaller number of posts lies in the willingness of university resident physicians to work overtime and in the use of highly efficient procedures. However, additional new structural and staffing requirements could easily rock this system.
Comparison of staffing codes for Level I and Level IV perinatal centers (27).
In addition, it needs to be taken into account that in accordance with requirements, a senior physician who is a qualified specialist in obstetrics has to be present 24 h a day, although this is not separately remunerated at the UPF. The corresponding remuneration would have a markedly negative influence on the operating results.
Investment costs. Due to the existing dual financing system, only the current operating costs of the UPF were included in the calculation. However, as there is uncertainty about how long hospitals will still be able to rely on the financing of investment costs by the individual states in Germany – it is currently estimated that there is an investment backlog of € 50 billion in Germany (28) – it would also be sensible to consider the operating result including the applicable investment costs. If all costs for building construction, renovation, maintenance, and new procurement of expensive equipment, etc. were to be taken into account, it is doubtful whether the annual operating results would be sufficient to cover these costs.
Costs in the framework of certified structures. In addition, the time and money expenses of a Level I perinatal center for research and teaching (29, 30), center coordination, training and further training, certification and recertification (e.g. in accordance with DIN/ISO), conducting research studies, and documentation were also not taken into account. The non-refundable nature of these costs in the current DRG system is an immense problem, particularly for certified hospitals. For this reason, these costs are often dependent on cross-financing by other specialist areas and on funds for research and teaching (25). As already pointed out by Köckemann and Lillteicher (22) and Beckmann et al. (25, 31), although there is a legal basis for the adequate provision of finance for the additional costs of certified centers in accordance with Section 5, Paragraph 2 of the Hospital Remuneration Law (Krankenhausentgeltgesetz, KHEntgG) (32), this entitlement on the part of the centers is at present usually not met.
Capacity provision costs. The costs of providing capacity for the interdisciplinary treatment of patients and neonates should be particularly emphasized. Since the UPF, as part of the Department of Gynecology in Erlangen, is able to cover a substantial proportion of its costs through cross-financing from other areas, an isolated analysis of the Level I perinatal center without the attached Department of Gynecology would have led to a poorer operating result. Particularly in the staffing area, the UPF is able to draw on personnel from the Department (e.g. with joint senior physician services and surgical nurses for gynecology and obstetrics). Although the problem of cross-financing applies particularly to staffing costs, completely isolated consideration of a Level I perinatal center would generally also lead to higher operating and administrative costs.
Prenatal diagnostics. The costs of the outpatient ultrasound clinic, with a negative contribution margin II of € 50,313, were not covered by the revenue obtained. There are various reasons for the failure of prenatal diagnosis to cover costs, as discussed in the report by the German Society for Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG) Finance Committee (25). For example, the full usage capacity of an ultrasound device is approximately 2,000 hours per year. For each ultrasound device in an outpatient ultrasound clinic, one senior physician post (€ 150,000/year), half a resident physician post (€ 40,000/year) and half a post for a physician's assistant have to be calculated. Overall, a total of 1,600 patients with a total of 3,500 visits and an average time of 30 minutes per visit should be examined per ultrasound device per year. This would result in full staffing costs of € 190,000/year per ultrasound device. A further € 15,000 per year is estimated for material costs. When these costs are allocated to the patients, approximately € 129 per patient and € 59 per examination are required to cover the staffing and material costs arising (25). With flat-rate revenues of € 94 per case, an outpatient ultrasound clinic at a university hospital is thus not capable of covering such costs. Despite this, the fact should not be overlooked that patients who present at a perinatal center's outpatient ultrasound clinic often also deliver their babies at the center (33). It is conceivable that the cost deficit is compensated for and that providing prenatal diagnosis offers a competitive advantage relative to other hospitals. Despite this, there is a justified demand for higher remuneration at least in order to cover the costs of highly specialized examinations. In addition, it should be taken into account that numerous non-university perinatal centers do not receive university flat-rate remuneration. In the absence of authorization, prenatal services may consequently be offered without the corresponding remuneration.
Case mix. A total of 79.4% of the case numbers at the UPF were distributed to five DRGs, all associated with pregnancies and neonates with the lowest risk profile: P67D (34.38%), O60D (25.37%), O01F (9.99%), O60C (5.65%), and O65B (4.01%). In contrast, obstetric DRGs associated with prematurity and high risk factors only represented 0.55% of all DRG case numbers at the UPF: O01A (0.14%), O02A (0.14%), and O60A (0.26%). Operating revenue was thus largely derived from care provided for uncomplicated pregnancies and births, the distribution of which is explained by the UPF's nature as a regional provider for the city and surroundings, in addition to being a maximum university-level provider of perinatal care. Any shifts involving loss of this low-risk group would have a marked negative effect on the operating results for a Level I perinatal center. Seelbach-Göbel (27) also showed that a Level I perinatal center mainly covers its actual costs through complication-free spontaneous births (DRG O60D) and would produce a negative operating result without these. By contrast, actual costs for cesarean procedures were not covered, by large margin. The cost of premature births in particular (O01A: € −2992, O01B: € −626), as well as births with several complicating diagnoses (O01C: € −846, O01D: € −343), and cesareans after the completion of 33 gestational weeks (O01E: € −332, O01F: € −233) were not covered (27).
Depending on its regional care provision status and the local competition, a Level I perinatal center is thus quickly capable of developing a deficit.
Limitations of the model. Due to individual differences between hospitals (involving staffing structure, trusteeship, special agreements, university outpatient departments) and differing regulations between the federal states in Germany, the present calculation is not fully transferable to every Level I perinatal center – and in particular, it is not transferable to other care-provision levels. A specific aspect that should be mentioned is the special agreement with Erlangen University Hospital's Pediatric Department for DRG revenue distribution. The neonatal intensive-care ward used to belong to Erlangen University Hospital's Gynecological Department. The flat-rate contribution of € 250,000/year by the Department of Pediatrics to Erlangen University Hospital's Department of Gynecology for all pediatric DRGs can be regarded as compensation for the fact that the Department of Gynecology thereby waives the sometimes very high charges derived from a neonatal intensive-care ward.
It should be taken into account that only staffing costs for physicians are charged via the outpatient pregnancy clinic. The remaining staffing costs for the outpatient pregnancy clinic are included in those of the delivery room. Due to the attached midwifery school, three additional full-time midwives were added to staffing costs in the delivery room, as midwifery trainees regularly carry out the work of qualified midwives.
Conclusion and Prospects
The present model showed a positive operating result for a Level I perinatal center under the conditions described. However, the discussion indicates numerous aspects and future influencing factors that are capable of endangering stability and undermining planning confidence. From the economic management point of view, the level of obstetric care which needs to be assessed carefully is reasonable for an institution and is also capable of being sustained in the future (34), particularly if additional material and staffing resources become necessary in order to meet G-BA requirements.
In the future, the operating results for a Level I perinatal center can be established on the basis of a process-oriented analysis. This requires detailed analysis of which processes require how much time, with average staffing costs per minute then being used to calculate how much these processes have cost in total. The study by Hornemann et al. (35) may be mentioned as an example of this. A third approach that may be mentioned is the study by Seelbach-Göbel (27), in which the actual costs of a perinatal center are compared with costs in the Institute of Hospital Remuneration (IneK) calculation. Finally, a fourth option for this type of approach that may be mentioned is the idea of establishing a generally valid cost accounting model that precisely corresponds to the G-BA requirements at the various levels of care. This type of model would certainly be extremely useful, but due to the individual differences between the various obstetric departments and perinatal centers mentioned above, it does not appear to be feasible.
To validate the actual cost and revenue structure of perinatal centers, further comparative calculations need to be carried out throughout Germany, so that regional and state-specific differences can be identified. It would be desirable for the present model to be validated by other perinatal centers at the same level of care provision, as well as other levels. This would make it possible to identify insufficient financing in the field of obstetrics and to further clarify the question of whether the quality of treatment in perinatal centers at the highest level of care provision is adequately remunerated in existing and future political, legislative, and competition-specific conditions in comparison with obstetric centers at lower levels of care provision.
Acknowledgements
We are grateful to the German Society for Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe e.V.) for awarding this study the First Poster Prize at the Society's 59th annual meeting in 2012.
Footnotes
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Conflicts of interest
None.
- Received June 15, 2013.
- Revision received July 15, 2013.
- Accepted July 17, 2013.
- Copyright © 2013 The Author(s). Published by the International Institute of Anticancer Research.
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