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AOP reform in context – impact on hospitals and alternative approaches.

The long-awaited and now published report lists 2,476 services in the area of outpatient surgery and inpatient-replacing procedures that are recommended for expansion of the AOP catalog. Based on the 2,897 OPS services included in the AOP catalog to date (2019), this would represent an expansion of 86 percent.

15. April 2022

AOP reform in context – impact on hospitals and alternative approaches.

Sarah Günther

The obligation to provide services on an outpatient basis will be significantly expanded in perspective

The long-awaited and now published report lists 2,476 services in the area of outpatient surgery and inpatient-replacing procedures that are recommended for expansion of the AOP catalog. Based on the 2,897 OPS services included in the AOP catalog to date (2019), this would represent an expansion of 86 percent.

More than a quarter of OPS services performed on a full inpatient basis are assessed as potentially feasible on an outpatient basis

The dimension of the OPS codes recommended for admission is reflected by the fact that they were performed about 15 million times for full inpatient treatment in 2019. This represents 26 percent of all ~58 million full inpatient OPS services (Figure 1). OPS services recommended for expansion were most frequently performed in the area of diagnostic measures (7.4 million times = 68 percent of services from Chapter 1). This mainly includes endoscopy of the esophagus, stomach and intestines.

Proportions of OPS services recommended for expansion out of the total frequency of inpatient OPS services performed by OPS chapter in 2019.

A case-specific context check should enable the systematic assessment in the specific treatment case

The decisive factor for the high number of OPS services that can be performed on an outpatient basis was the potential-oriented approach chosen by the experts. This exposed opportunities for outpatient performance of various OPS codes. Against this background, the implementation of a case-specific context check is recommended. Depending on the individual treatment situation, this may justify an inpatient stay. The context check is also to be the basis for the legally required severity differentiation for a remuneration model yet to be developed.

A new section is to be created in the AOP catalog for the addition of non-surgical services

In addition to the catalog described on the basis of the OPS system, the experts recommend a number of DRGs to also push the outpatientization of non-operative (“conservative”) treatments in lieu of hospitalization. However, outpatient feasibility in this case is partly linked to not insignificant structural prerequisites, such as the possibility of immediate inpatient treatment and clarification.

Implications for hospitals

The ball is now in the court of the self-governing partners

On the basis of the report, the self-governing partners must adapt and expand the AOP catalog and agree on uniform remuneration for hospitals and contract physicians. This mandate is particularly urgent now that the coalition agreement also addresses ambulantization as an important part of the intended structural reform. The task now is to translate the great potential of outpatient care, which has been discussed enough, into meaningful structures.

A gradual implementation is to be assumed

Only a comparatively manageable portion of the proposed new AOP services can be implemented in the short term through an ad hoc adjustment of the catalog (decision in the summer, entry into force at the turn of the year). Far-reaching adjustments are only possible once the necessary structural and organizational conditions have been met to ensure quality-assured care and to remunerate it accordingly. The development of a viable remuneration system linked to a differentiation of severity is a considerable challenge in this context. The agreement process between the self-government partners can significantly delay further steps. In addition, it can be assumed that only part of the described potential will find its way in. It is currently almost impossible to reliably forecast the scope of the project

Various services are only conditionally suitable for contractual medical care

Hospitals can often be the right place for outpatient services due to the necessary structural requirements that usually exist there anyway. In the case of sector-equivalent remuneration by means of the hybrid DRGs envisaged in the coalition agreement, this could be a strong incentive for the outpatient provision of services formerly provided on an inpatient basis. However, continuing to provide inpatient services is unlikely to cover costs economically unless the individual case assessment explicitly allows for this. Hospitals must equip themselves accordingly for outpatient service provision, both structurally and in terms of personnel.

Intersectoral forms of care as an alternative structure for service provision

The planned expansion of services that can be performed on an outpatient basis is also interesting in terms of its feasibility in the setting of new care concepts such as intersectoral health centers (IGZ). These are located in the outpatient sector, with their services and infrastructure going beyond the traditional outpatient service portfolio. IGZs also include so-called extended outpatient care (EAV), which is provided in a bed-based unit. These structures could thus address well the needs associated with the structural requirements of outpatient treatment, some of which are more complex. Oberender AG, in cooperation with the Institute for General Medicine and Interprofessional Care at the University Hospital of Tübingen, has prepared a current expert report. This identifies the potential volume of services that can be shifted from inpatient care to other care structures. The order of magnitude is broadly consistent with the findings of the AOP reform report.

Review and outlook

With the MDK Reform Act passed in 2019, the legislature had commissioned GKV, DKG and KBV to submit a joint expert opinion on the reform of the AOP catalog. In April 2022, the comprehensive work was presented by the IGES Institute. It would be a fatal misjudgment to conclude from this long period of time and the hurdles still to be overcome that hospitals still have time before they have to deal with the issue. The trend is clear, and in times of increasingly tight budgets, political pressure to act may well shorten decision-making processes. At the same time, in order to be able to provide these services on an outpatient basis, many hospitals first have to create structural conditions and adapt their organization and processes to the new requirements. This often also requires a profound cultural change that can only be brought about over a longer period of time. Appropriate preparation and support significantly increase the chances of success.

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Sarah Günther


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