[Cost and revenue analysis of inpatient and outpatient cases in emergency departments: potential for optimization and control?]

backgroundA precise economic representation of the central emergency department (ZNA) is a challenge for most hospitals. Due to the complex interrelationship of revenues from various systems, internal service billing, costs associated with the German Association of Statutory Health Insurance Physicians (KV), and process indicators, there are currently no analytical models that provide full transparency regarding the economic reality of the ZNA, and, thus, there is no solid basis for differentiated management.

methodsIn a retrospective, quantitative study based on routine data (n = 150 cases) from 2024 from the Charité - Universitätsmedizin Berlin emergency department, which was selected based on specific criteria, a cost and revenue analysis was performed. In addition, resource intensive formal "hybrid cases" that were billed formally as outpatients but with inpatient characteristics were defined and included in the analysis, which until now have not been adequately reflected in any renumeration system. The term "hybrid" describes formal outpatient but resource intensive processes with inpatient characteristics. Personnel costs were not analyzed based on each case due to lack of a reliable method to assign these to the individual cases.

resultsRemuneration was inadequate in nearly all outpatient cases (-242 to -346 €/case depending on the Charité site). Hybrid cases form an especially critical group (-205 to -290 € per case depending on the site) due to the longer hospital stay and higher costs in the internal cost allocation (ILV). In some cases, inpatient cases had more favorable remuneration ratios and thus appear to be more cost-effective due to internal splitting logic. However, because only about 22 % of cases are hospitalized, while 78 % remain outpatients, the inpatient minority can not compensate for the structural deficits of the outpatient majority. The economic outcome is also negatively affected by the about 10 % costs associated with the KV. DISCUSSION AND

conclusionThe systematic integration of cost, revenue, and process data is feasible and generates new information for management, but it remains incomplete due to limitations in the routine data. The results show that the economic difficulties of the ZNA are not primary due to the inefficient provision of services, but are due to structural causes of renumeration logic in the German healthcare system. The internal establishment of specific management tools, especially the linking of ILV, hospital stay duration and case type ("hybrid flag"), can contribute to improvements, but can not overcome the structural deficit. This structural underfinancing of emergency preparedness exacerbates the already strained financial situation of hospitals and requires future reform that explicitly takes into consideration aspects of standby capacity components and the actual provision of services.