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Purpose: In 2015 the remuneration system for psychiatric and psychosomatic stationary treatments will be revised. The remuneration for a case is calculated by the product of base rate, a cost weight and the number of days of treatment. The cost weight varies depending on the number of days of treatment. This paper surveys the incentives, the casemix structure and the consistency of the modified PEPP system., Methods: Under the assumption of a profit-maximising supplier it is possible to define the economically optimal length of stay by comparing marginal revenues and marginal costs. Therefore a revenue function is derived from the new structure of the PEPP system. Since the determination of the marginal revenues is not mathematically possible, the revenues per additional day of treatment are calculated. On that basis it is possible to determine the economically optimal length of stay and to assess the consistency of the system changes., Results: In an early stage of treatment the revenues per additional day of treatment are degressive. After a defined amount of days these additional revenues stay constant, which will be relevant for the majority of the cases. It is economically optimal for the hospitals to treat patients as long as possible, if the marginal costs lie or sink below these constant revenues per additional day of treatment. Furthermore the system changes result in a more complex casemix structure and the calculation of the cost weights is partially inconsistent, since the marginal revenues do not monotonically decrease., Conclusions: The modifications lead to a reduction of degressive elements in the PEPP system, which might also be accompanied by a decrease of economically induced pressure on length of stay. The inconsistent calculation of the cost weights and the more complicated casemix structure can be viewed critically., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The German fixed rate remuneration system in psychiatry and psychosomatics (PEPP) has been criticized by many specialty associations because negative effects on mental healthcare are expected through economic incentives., Objective: Through analysis of performance data in the treatment of alcohol dependency at the Evangelical Hospital Bielefeld (Evangelisches Krankenhaus Bielefeld, EvKB) from 2014 and various simulations, the incentives of the PEPP (version 2015) were analyzed and its potential impact on patient care was evaluated., Methods: Groups of cases were created based on the clinical data. Various parameters were evaluated, such as duration of treatment, PEPP coding, loss of income by merging cases and case remuneration. Additionally, changes in the duration of treatment, the intensity of treatment and the intensity of care were simulated., Results: In the simulations a reduction in the duration of treatment by 16.1 % led to additional revenues of 1.9 % per treatment day. The calculated additional costs of 1:1 care and intensive nursing care were not completely covered by the additional revenues, whereas psychotherapeutic inpatient treatment programs showed positive profit contributions. Complicated cases with increased merging of cases showed lower revenues but with above average expenditure of efforts., Conclusion: The current version of the PEPP leads to misdirected incentives in patient care. This is caused, for example, by the fact that higher profit contributions can be realized in some patient groups and intensive nursing care of patients is insufficiently represented. It is not clear whether these incentives will persist or can be compensated in subsequent versions of the system.

A new remuneration system is currently being developed for the hospital care of people with mental disorders. Last year, because of sharp criticism the option phase of the planned Flat-rate Charges in Psychiatry and Psychosomatics (Pauschalierende Entgelte Psychiatrie und Psychosomatik, PEPP) was extended by 2 years. During this time the Federal Ministry of Health wants to look for alternatives and possible starting points for the further development of care. Now, 16 scientific professional associations and organisations have presented a joint concept for a sustainable solution: the budget-based remuneration system. The system is suitable for ensuring that people with mental disorders are treated according to their particular needs and for promoting the appropriate further development of regional care in all treatment settings. It corresponds with the objectives as formulated in Section 17d of the Hospital Finance Act (Krankenhausfinanzierungsgesetz, KHG) and translates the PEPP system, which is currently being developed and focusses on average prices, into a performance-oriented, transparent budgetary system. The fundamental principle is the separation of the individual hospitals' budgeting on the basis of evidence-based, feature- and performance-related modules and billing in the form of advance payments from the agreed budget.

Purpose: This paper surveys the effects of day-based lump-sum remuneration as defined by the PEPP system on the patients' length of stay and compares its incentives to the mechanisms of the German DRG system and the former remunera-tion system for stationary psychiatric and psychosomatic treatments., Methods: The analysis identifies the economically optimal length of stay defined as the profit maximising duration of treatment by comparing marginal revenues and marginal costs. Since it is economically optimal to extend the treatment until the marginal costs exceed the marginal revenues, psychiatric and psychosomatic facilities are incentivised to minimise the time gap between average duration of treatment as expected duration of treatment and the economically optimal length of stay., Results: Compared to the German DRG system, which provides a strong incentive to reduce length of stay, the incentives set by the PEPP system imply either a reduction or an extension of treatment duration depending on the underlying cost function. If a degressive cost function is assumed, which is typical for treatments of psychiatric and psychosomatic illnesses, the economically optimal duration of treatment will be at the last upper boundary of the interval of the marginal revenue function in which the average marginal revenues exceed the average marginal costs. It is also feasible that it is economically optimal to treat the patient for as long as possible. The hospital is incentivised to extend or reduce the time of treatment to this point in time., Conclusions: Psychiatric and psychosomatic hospitals are able to increase their profits by reducing or extending time of treatment. Therefore these facilities have to justify the extent of treatment to the health insurance companies. Since the incentives of the PEPP system and the DRG system diverge, the results of research on supply induced demand in the DRG system cannot be transferred to the discussion about the effects of the introduction of the PEPP system. As long as the average duration of treatment as expected duration of treatment deviates from the economically optimal length of stay, policy makers should consider the options of adaptations, i. e., increase of time intervals or calculating cost weights based on variable costs combined with separate remuneration of fixed costs. The TEPP system and PEPPplus are already being discussed as adaptions or additions., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: There is a high degree of misallocated medical care for patients with somatoform disorders and patients with concomitant mental diseases. This complex of problems could be reduced remarkably by integrating psychosomatic departments into hospitals with maximum medical care. Admitting a few big psychosomatic specialist clinics into the calculation basis decreased the Day-Mix Index (DMI). The massive reduction of the calculated costs per day leads to a gap in funding resulting in a loss of the necessary personnel requirements - at least in university psychosomatic departments. The objective of this article is therefore to empirically verify the reference numbers of personnel resources calculated on the basis of the new German lump-sum reimbursement system in psychiatry and psychosomatics (PEPP)., Methods: The minute values of the reference numbers of Heuft (1999) are contrasted with the minute values of the PEPP reimbursement system in the years 2013 and 2014, as calculated by the Institute for Payment Systems in Hospitals (InEK)., Results: The minute values derived from the PEPP data show a remarkable convergence with the minute values of Heuft's reference numbers (1999)., Conclusions: A pure pricing system like the PEPP reimbursement system as designed so far threatens empirically verifiable and qualified personnel requirements of psychosomatic departments. In order to ensure the necessary therapy dosage and display it in minute values according to the valid OPS procedure codes, the minimum limit of the reference numbers is mandatory to maintain the substance of psychosomatic care. Based on the present calculation, a base rate of at least 285 e has to be politically demanded. Future developments in personnel costs have to be refinanced at 100 %.

The development of the lump-sum reimbursement System in psychiatry and psychosomatics (PEPP) (Klimke et al., 2014) is being negatively considered - also in gerontopsychiatry.Thus it is reasonable to make a timely analysis of the effects of PEPP on health-care structures. For this two analyses have been carried out. On the one hand the day mix index of elderly patients (> 64 years) was compared with that of younger ones (> 17 years, < 65 years). On the other hand younger and older were included in the analysis with regard to the available treatment minutes in exact daily classifications according to the PsychPV. It is seen that evaluation of the individual day was markedly higher for gerontopsychiatric patients not only in inpatient (difference > 0.1) but also in outpatient (difference > 0.07) setting. The exact daily classifications according to PsychPV, however, were markedly poorer for the elderly patients. Thus, on the basis of routine data of VIPP projects, a clear change can be seen in favour of the elderly patient under PEPP conditions as compared to financing according to PsychPV. However, concern remains that the ageing population and modernisation of therapy are not being sufficiently taken into account. The new reimbursement system merely regulates the distribution of available resources; if these resources are too low nothing will change by the PEPP-System., (© Georg Thieme Verlag KG Stuttgart · New York.)

With the implementation of § 17 d KHG which provides for the introduction of a new, much more performance-based and transparent reimbursement system for psychiatric and psychosomatic hospitals, the Federal Ministry of Health sends the psychiatric and psychosomatic facilities in Germany into a previously unexplored area. Since 2013, there is the possibility of voluntary participation in the new system. Valid from 2015, every other institution will have to deal with the new challenges, opportunities and risks coming along with the structural changes, even though this fact will not have any impact on the individual hospital revenue budget until the end of 2016. There is still some time left to get used to the new system. This paper summarises the key data on the new reimbursement system and explains its content as well as how it works. In addition to that this paper goes into the classification system and clarifies what is essential for a solid preparation. Finally, it comments on the most common criticisms emerging since 2009. How the new system will develop remains to be seen. The fact that it will evolve seems to be certain in terms of a "learning system". It is up to all parties to promote the learning process so as to make effective use of existing potential and keep risks to a minimum., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: In Germany a new reimbursement system for psychiatry and psychosomatics is under development. Based on total costs of each case from selected hospitals and day clinics, in 2013 the Institute for the Hospital Remuneration System (InEK) proposed to reimburse the hospital costs daily with step-wise decreasing remuneration, mainly depending on the ICD-10 diagnosis, duration of stay and some complicating factors (PEPP grouper). It is controversial whether this degressive system will result in an inadequate remuneration of patients with longer duration of severe symptoms, such as suicidality in depression or autoaggressive behavior in borderline personality disorder and will eventually lead to advantages for acutely ill patients with short duration of stay compared to chronically ill patients., Objectives: This study formulated and tested an alternative remuneration system (proof of concept) mainly based on an analysis of daily cost data instead of the total costs of each case., Material and Methods: The study is based on 147,749 treatment days from 4,633 cases of patients with psychotic disorders (PEPP-PA03) in 6 hospitals. As possible cost separating factors the study analyzed days with and without intensive psychiatric care, 1 to 1 care, psychological diagnostics, magnetic resonance imaging (MRI), acute crisis intervention, age at admission, the first days of treatment and day of discharge., Results and Discussion: Nearly all factors tested were shown to be statistically significant in separating daily hospital costs. Based on these findings an alternative calculation algorithm (TEPPconcret), which grouped the cases with respect to age, intensive care, 1 to 1 care, treatment days 1-4 and day of discharge, was formulated and tested. For psychotic disorders TEPPconcret with a basic rate complemented by daily add-on payments depending on the effort involved, is a serious alternative to the PEPP system and awaits further evaluation.

Introduction: Quality assurance in psychosomatic medicine in Austria is currently based on a voluntary continuing medical education programme in psychosocial, psychosomatic and psychotherapeutic medicine. It is questionable whether psychosomatic care can be sufficiently provided in this manner. In addition, a broadly based proposal to create a subspecialty in psychosomatic medicine in order to facilitate quality assurance, is investigated., Methods: The necessity to reorganize psychosomatic care was explored through semi-structured qualitative interviews with experts. Data-based analyses probed the labour market of the proposed subspecialty, and the literature was reviewed to look into the cost-benefit ratio of psychosomatic treatment., Results: All experts expressed a need to restructure psychosomatic care in Austria. Examples exist for psychosomatic treatment with an efficient cost-benefit relation in diverse medical settings., Conclusion: Establishing a subspecialty in Psychosomatic Medicine seems feasible and could contribute to increased quality assurance and the nationwide provision of psychosomatic care.

Objective: Various western countries are focusing on the introduction of reimbursement based on diagnosis-related groups (DRG) in inpatient mental health. The aim of this study was to analyze if psychosomatic inpatients treated for eating disorders could be reimbursed by a common per diem rate., Methods: Inclusion criteria for patient selection (n=256) were (1) a main diagnosis of anorexia nervosa (AN), bulimia nervosa (BN) or eating disorder-related obesity (OB), (2) minimum length of hospital stay of 2 days, (3) and treatment at Charité Universitaetsmedizin Berlin, Germany during the years 2006-2009. Cost calculation was executed from the hospital's perspective, mainly using micro-costing. Generalized linear models with Gamma error distribution and log link function were estimated with per diem costs as dependent variable, clinical and patient variables as well as treatment year as independent variables., Results: Mean costs/case for AN amounted to 5,251€, 95% CI [4407-6095], for BN to 3,265€, 95% CI [2921-3610] and for OB to 3,722€, 95% CI [4407-6095]. Mean costs/day over all patients amounted to 208€, 95% CI [198-218]. The diagnosis AN predicted higher costs in comparison to OB (p=.0009). A co-morbid personality disorder (p=.0442), every one-unit increase in BMI in OB patients (p=.0256), every one-unit decrease in BMI in AN patients (p=.0002) and every additional life year in BN patients (p=.0455) predicted increased costs., Conclusion: We see a need for refinements to take into account considerable variations in treatment costs between patients with eating disorders due to diagnosis, BMI, co-morbid personality disorder and age., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: Actual codes for operations and procedures (OPS) in psychiatry and psychosomatics should map cost separating therapeutic activities so far defined in Germany by the normative specifications of the psychiatry staff enactment (PsychPV). OPS codes should also allow re-estimating underlying therapy times., Method: Therapeutic activities of the PsychPV fulfilling the minimal criteria of the OPS definition were classified as multiples of a therapeutic 25 minute unit., Results: Therapeutic activities of the PsychPV are mapped to OPS complex codes in a variable degree (psychiatrists 35 %, psychologists 42 %, nurses 43 %, special therapists 59 %)., Conclusion: Actual OPS codes are inappropriate for identifying relevant cost-separating factors in the therapy of psychiatric in-patients. They cannot assure in their actual form the standards given by the PsychPV and need substantial revision., (© Georg Thieme Verlag KG Stuttgart · New York.)

Over the last 40 years the proliferation of the biopsychosocial (BPS) model across clinical and theoretical research has shown that psychosocial factors can be shown to be causes, co-factors, or sequelae of many illnesses. Scientific presuppositions about the BPS model have been grounded firmly in psychobiological, psycho-behavioural, sociobiological, and socio-behavioural processes. According to the allostatic load model, stressful factors can be psychological ones or any other factor that is able to modify the stress-response system; these might include genetic factors or life experiences. Personality profiles, in particular, seem to be predictive of responses to different stressors. Stress responses preceding or following illness are clearly related, from a psychobiological point of view, to different personality traits, which themselves correlate to specific defence mechanisms. Neural processes underlying these mechanisms interact with the biological substrate of somatic illnesses. Recent advances in brain imaging with regard to neurobiological and behavioural interactions of empathy and alexithymia support the crucial role of the (psycho) therapeutic relationship across the whole of medical practice. Psychotherapies operate as biological factors on mind, brain, and body; indeed it is necessary to reconsider the doctor-patient relationship as a psychotherapeutic process. The basic methodological triad of observation (outer viewing), introspection (inner viewing), and dialogue (inter viewing) becomes essential in medical practice and in scientific research. Psychoanalytic processes such as transference, resistance, the therapeutic alliance, and attachment have been reconsidered from a neuroscientific perspective and reconceived as moments of meeting of the procedural memory and are therefore considered relevant to the relationship with patients in primary care. Indeed, they are useful to an ethical approach to understanding the meaning of illness, and they also influence the results of treatment projects. Because all these aspects impact upon illness duration and quality of life, affecting both the individual concerned and his or her family, the economic consequences of this psychosomatic approach are important in both general and specialist medicine. Medicine is becoming, and will become even more in the future, an integrated science; human illness and the maintenance of good health may be better understood if all medical disciplines are considered as a whole. The domain of psychosomatic medicine has now extended to coincide with that of medical practice. There is increasing evidence, not only in psychiatry, but in all medical fields, that care of the mental well-being of a person is essential for effective care of the body. Not only mens sana in corpore sano, but also corpus sanus in mente sana.

In March 2009 the "Krankenhausfinanzierungsrahmengesetz (KHRG)" (Hospital Finance Law) came into force. For this reason, new procedures covering psychosomatic-psychotherapeutic und psychiatric-psychotherapeutic inpatient treatment had to be developed. This paper presents the new Psych-Procedures (Psych-OPS) together with first instructions on coding procedures.

The decision of the German legislator to limit rehabilitation programme participation under the health-insurance scheme to a duration of three weeks had been oriented less by rehabilitation-scientific findings rather than by economic considerations. This is the background for discussing the question to what extent medical experience and empirical data are providing new information as to the durations of rehabilitation necessary and feasible in the field of psychosomatic rehabilitation and as to measures capable of supporting its effectiveness without extending the duration of therapy.

In the German DRG system the funding of CL services is not ensured. The documentation of psychiatric comorbidity and CL care delivery is a pre-condition to the development of funding models for CL-services. A task force of several German psychosomatic associations (German College of Psychosomatic Medicine, German Society of Psychosomatic Medicine and Psychotherapy, General Medical Society for Psychotherapy) developed a new documentation form for CL-services (CL-BaDo). The pilot study explored the multicenter implementation of CL-BaDo and the use of the documentation form for quality management and cost calculation. Over a period of at least three months, participating CL-services documented all CL cases consecutively with the CL-BaDo. One site applied full electronic data processing. 2116 CL cases from eight psychosomatic CL-services were analysed. The CL-BaDo is a time-efficient, feasible and acceptable documentation form for CL-service delivery. The full electronic data processing enables networking with a hospital information system to produce higher data quality. The data of CL-BaDo can be used locally for quality management, development of management strategies and communication with consultants, as well as nationwide for health policy questions and research.

This paper, summarizing the activities of the research task force of the German College of Psychosomatic Medicine (DKPM), reviews how research in psychosomatic medicine, medical psychology and psychotherapy has been funded by different institutions. The review reveals that psychosocial research has received considerable grants especially by the German Research Council and the Federal Ministry of Education and Research but also from other funding institutions. Besides an overview of potential sources for funding in the psychosocial disciplines, recommendations are formulated that might be helpful for raising research funds in the future.

The medical diagnoses and their economic level of severity as well as the treatment costs and the proceeds of an integrated internal - psychosomatic ward C were compared with two conventional internal wards A and B of a general medical department within a hospital of tertiary care level. With a similar economic level of severity of the diagnoses, lethality and costs for nursing care given the medical treatment costs of C were significant lower and the proceeds (minus medical treatment costs and nurses' salaries) calculated according to G-DRG version 1.0 higher than those of A and B. Integrated internal medicine is more cost effective compared to conventional internal medicine.

The medical ideology being based on structure instead of function (specifically on the cgs-logic--centimetre, gram, second) instead of a patient-orientation, the patient's resources are rarely ever even touched. This is the basis for operating difficulties in self- and patient-management. Changes of this uneconomic approach should centre on training, focusing especially on how to increase the professional's sensitivity for the relationship with his patient. Unfortunately, Austria's situation is characterized by deficitary psychosomatic competence in medical professionals. In addition, the absence of universitary or other structures centering on psychosomatic training and co-ordination is to be criticized. An interuniversitary-psychosomatic structure in Austria is proposed as a starting-point to overcome these serious short-comings.

Within the last decade cost-effectiveness assumes a much more strategic perspective in the rationing of care that is taking place due to evidently increasingly limited financial resources and managed-care driven protocols. As universities and general hospitals face this increasing pressure to justify services within their facilities, consultation-liaison (C/L) programs need to carefully address and evaluate the financial base of the services they provide. Overlooking or neglecting the financial aspects of C/L-services has already resulted in the closure or service reduction of C/L-programs throughout the United States. Whereas a result of that development interest in cost-effectiveness research is considerable in the US and GB and has produced some good evidence for the impact of psychosocial problems on the outcome and cost of medical care, nearly no such studies come from the German-speaking countries. The present article reviews the worldwide existing literature concerning cost-effectiveness analyses of C/L-work and attempts to guide the reader through the currently available methods for cost-effectiveness research. As a conclusion we propose somatisation syndromes as one patient group. There the development of appropriate treatment regiments is vital both concerning clinical and socioeconomical aspects.

Economic evaluations have become more and more important in the somatotherapeutic field. This survey's objective was to examine if the current economic evaluation techniques can be applied to psychotherapy. 8 data banks, 17 key words from the psychotherapeutic field and 14 economic key words were used, the identified original studies were classified in accordance with Drummond, the methodical quality of each study was assessed at a score between 0 and 10 points. 21 studies were found: 16 cost-benefit analyses, 4 cost-effectiveness analyses and one cost-utility analysis. The quality of the representation of the clinical results (mean value 8.6) was better than that of the economic results (mean value 6.1). It was perfectly possible to evaluate psychotherapeutic interventions with regard to economic aspects by means of the current techniques but in most cases there was a considerable lack of quality in both representation and calculation. Furthermore the evaluation type of cost-utility analysis, which is the only one that takes quality of life aspects into consideration and therewith seems to be the most appropriate approach regarding the psychotherapeutic field, has been greatly ignored.

All of the programs in the Academy of Psychosomatic Medicine directory of U.S. consultation-liaison (C-L) fellowship training (N = 49) responded to a questionnaire to document composition and funding of their staff. The mean annual budget was $324,664 (range $40,000-$550,000), with a mean of 2.4 full-time equivalents and 1.6 fellowship training positions. A significant patient cohort and C-L staff and fellows exist in these programs to launch important hypothesis-generation studies.