Insufficient Reimbursement for Complex Aortic Arch Procedures within the German DRG System

Background: According to the recent German Heart Surgery Report 2021 by the Society for Thoracic and Cardiovascular Surgery, 7,499 aortic procedures are performed yearly in Germany with the use of ECC (12% of ECC procedures; + ~5% vs. 2020). A total of 2,815 aortic arch procedures were reported. Although aortic surgery constitutes a significant portion of the heart surgery work load, no specific DRG exists for these procedures. Especially complex aortic arch procedures (e.g., total aortic arch repair with frozen elephant trunk [FET]) consume a significant amount of resources and seem to be underfunded. We investigated costs and reimbursement of these procedures in our institution.

Method: Between January 2013 and November 2020, a total of 274 patients underwent complex aortic arch repair with FET in our institution (university hospital). For 254 patients (93%) complete datasets on costs and reimbursement were available. DRG characteristics were evaluated: DRG group, DRG revenue, additional revenue, costs, contribution margin (Deckungsbeitrag), calculated length of stay, actual length of stay. Clinical outcome parameters were assessed.

Results: DRG grouping of all 254 cases led into 19 different DRGs. 185 cases (73%) were covered by five DRGs (F03A: N = 64 [25%]; F07A: N = 51 [20%]; F05Z: N = 37 [15%]; A13B: N = 17 [7%]; A13A: N = 16 [6%]). The median contribution margin (Deckungsbeitrag) was −16.346 € (IQR: −16.346€; −3.765€). Only in 30 cases (12%) the contribution margin was positive (median: 4.819€; IQR: 2.630–9.883€). Contribution margin did not differ significantly between the five most common DRG groups. Overall median costs were 55.722€/case with a wide range from 30.245€ up to 329.864€. Overall perioperative mortality (30 days + in hospital) was 19%. Contribution margin was significantly worse in non-survivors (median: −15.930€ vs. −10.290€, p = 0.04). Calculated length of stay and actual length of stay did not differ significantly (p = 0.35). 144 survivors (57%) had a length of stay of ≤21 days. This group of “good clinical outcome” cases showed a significantly better contribution margin (−6.544€ vs. −14.997€, p < 0.0001).

Conclusion: Complex aortic arch surgery with FET seems to be grossly underfunded by the DRG system with a median loss of −16.346€ per case in our institution. In average, cases with favorable clinical outcomes showed a smaller degree of underfunding. Further investigations will evaluate cost drivers. We suggest that specific DRGs are introduced for open aortic surgery procedures that adequately reflect the financial burden of these cases.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
28 January 2023

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