Downgrading of a hospital in the G-BA's tiered system of emergency structures Quality control by the MD
Hospital locations that participate in emergency care are categorized into three levels according to the corresponding G-BA guideline:
Level 1: Basic emergency care
Level 2: extended emergency care
Level 3: comprehensive emergency care
Hospital sites that do not participate in emergency care are subject to remuneration deductions. For each level, the G-BA guideline sets out specific requirements for the personnel, structural and medical-technical equipment of the respective hospital site. These requirements are set out in detail in the Federal Joint Committee's guideline on a tiered system of emergency structures in hospitals. If the requirements are met, the hospital is classified accordingly. If one of the necessary requirements is not met, a location can be downgraded or released from emergency care.
Quality control by the MD
Compliance with the requirements is checked by the Medical Service (MD) as part of quality controls. The procedure for carrying out the inspections is regulated by law in Section 275a SGB V and detailed in the G-BA's MD quality control guideline. The procedure is initiated by commissioning the MD by an authorized body. The application for inspection is usually submitted by a statutory health insurance fund, Part A Section 5 (1) (b) of the MD Quality Control Directive. Furthermore, the respective state working group of the KV, KZV, LKG and the state associations of the health insurance funds, for example, is authorized to commission the MD (Part A § 5 Para. 1 lit. a MD-Quality Control Directive in conjunction with Part 1 § 5 Para. 1 Deut. 1 of the MD Quality Control Directive). Part 1 § 5 para. 1 DeQS-RL).
The inspection of compliance with the minimum requirements specified in the regulations on emergency structures can be carried out on the basis of evidence or as a random sample inspection (Part B Section 3 § 25 Para. 3 6 MD-Quality Control Directive).
The MD prepares an inspection report on its quality control, which it forwards to the hospital operator and the commissioning body (health insurance fund, state working group) (Part A, §§ 5, 6 MD Quality Control Directive).
Hospital response options in the event of a negative inspection report
If the MD comes to the conclusion that a hospital previously classified at emergency level 3 should only be assigned to level 2 (or that a level 1 hospital should be discharged from emergency care), the question arises as to how the hospital can react to this. For example, if the MD determines that there is no continuous possibility of percutaneous coronary intervention (PCI) at all times (24 hours, 7 days a week) (Section 21 (1) No. 2 Directive on a tiered system of emergency structures in hospitals).
Applying for a new quality control
First and foremost, the hospital can apply to a commissioning body for a renewed quality control by the MD in order to be able to prove that the quality deficiencies identified by the MD have been rectified (Part A Section 15 Para. 4 MD Quality Control Directive). In these cases, the quality control must be carried out by the hospital within twelve weeks of the application being submitted, insofar as this is necessary to determine the elimination of the deficiencies.
In this way, the hospital can achieve a determination that the deficiencies have been rectified. However, this presupposes that the deficiencies have been rectified beforehand. In the above example, the hospital may have concluded a cooperation agreement with a suitable service provider to ensure PCI at all times.
Remuneration consequences of downgrading
The increases and reductions in remuneration resulting from the respective emergency level of the hospital are based on the emergency level remuneration agreement between the GKV-SV, the DKG and the Association of Private Health Insurers. Further details can be found in § 1 of the agreement:
It follows from this that the parties to the care rate agreement (i.e. hospital operators, hospital operators and social service providers/joint ventures of social service providers) examine the fulfillment of the minimum requirements for participation in emergency care and bindingly determine in which emergency level or in which module of special emergency care the hospital location is to be classified. The review and classification takes place as part of the budget negotiations.
If no agreement can be reached on the classification of the hospital site, the arbitration board can be called upon in accordance with Section 18a KHG (Section 1 (1) sentence 3 of the agreement).
The classification of a hospital location is determined for the respective agreement period. The determination remains binding until the parties to the nursing rate negotiations have made a new determination for the following agreement period (Section 1 (2) of the agreement).
The negative MD control report is included in the budget negotiations via the health insurance funds if the minimum characteristics of an emergency level are not met. In this way, the negative MD control report can lead to a corresponding loss of surcharges or, if the emergency level is completely eliminated, to deductions.
Procedure
It is therefore recommended that hospital operators first check the formal and substantive legality of the MD control report: Has the procedure of the MD Quality Control Directive been followed? Are the deficiencies identified by the MD actually present? If so, how can the deficiencies be rectified? For example, deficiencies in the medical-technical equipment can be remedied by concluding appropriate cooperation agreements with suitable service providers and thus ensuring 24/7 availability for the CT, for example (Section 11 (2) of the Emergency Level Directive). If necessary, staffing can be ensured through appropriate on-call services, etc. What is legally possible and actually feasible must be examined on a case-by-case basis.
As soon as the deficiencies have been rectified, the hospital should apply for a renewed quality control by the MD to an authorizing body (Part A § 15 Para. 4 MD Quality Control Directive). In our opinion, it should be explained in writing how and with which measures the deficiencies identified by the MD were responded to and how these deficiencies were rectified. This document should be made available to the parties to the care budget negotiations so that, in the event of ongoing negotiations, the MD's new inspection report can be awaited.
We will be happy to assist you in reviewing the MD inspection reports and help you to rectify the deficiencies identified.