Reimbursement varies from country to country. In some cases, the ‘architecture’ of reimbursement is very different, and may profoundly affect the likely success of your business proposition. In other cases, the way the system deals with a technology is similar, although the details — particularly cost — can differ. One technology which is interesting for showing both similarities and differences between countries is dialysis for acute kidney injury.

Acute kidney injury describes a spectrum of acute injury of varying severity to the kidneys, causing a reduction in kidney function and resulting in failure of the organs to maintain fluid, electrolyte and acid-base homeostasis. Hemodialysis is required to carry out the function of the kidneys and remove chemicals, wastes ad extra fluid from the blood. This condition is distinct from chronic renal failure requiring long-term treatment, with a possible transplant.

England

In England, relevant procedure codes for acute renal dialysis are mapped to the following Healthcare Resource Groups codes (HRGs, the UK version of DRGs) for reimbursement purposes:

• LE01A (Haemodialysis for Acute Kidney Injury, 19 years and over);

• LE01B (Haemodialysis for Acute Kidney Injury, 18 years and under);

• LE02A (Peritoneal Dialysis for Acute Kidney Injury, 19 years and over); and LE02B (Peritoneal Dialysis for Acute Kidney Injury, 18 years and under).

These HRGs apply, provided that a diagnosis of acute renal failure or acute kidney injury specified in a list is also recorded.

The HRGs are also ‘unbundled’: any reimbursement for these HRGs is additional to any other reimbursement which might apply to the hospital stay.

‘Non-mandatory’ tariffs are published for LE01A (£655) and LE01B (£336). Non-mandatory tariffs are benchmarks for payers and providers when negotiating local prices. These prices benchmark the whole of the dialysis cost incurred by the hospital in the course of the related hospital admission (i.e. the local price, based on these benchmarks, will be ‘per stay’ and not ‘per session’ or ‘per day’.

No tariffs are published for HRGs LE02A and LE02B. Prices are negotiated locally, without any published benchmark data.

‘Best Practice Tariffs’ (BPTs) for adult renal dialysis are also published but explicitly do not apply to acute kidney injury.

Proposals for 2016-17 (which also involve a move to a new version of HRGs, HRG4+) leave the mapping of procedures to HRG codes unaltered. However, ‘mandatory’ prices have now been published for LE01A (£586) and LE02B (£335). These prices will no longer be negotiated locally: payers and providers must use these prices. Under the proposals for 2016-17, no tariff is now published for HRG LE01B, and HRG LE02B continues to have no tariff published. Prices for HRGs LE01B and LE02B continue to be set locally, without any published benchmark tariff.

All four HRGs will continue to be unbundled. So, for example, a hospital stay admitted with a principal diagnosis of acute kidney injury with interventions, with a mid-range complications score might attract reimbursement of £5,220, and without interventions £3,721, to which would be added the figure for the ‘unbundled’ HRG generated by the dialysis. The mandatory tariffs for the stay are ‘all in’, except for the dialysis, and are single payments covering the whole of the stay. An additional per diem is payable for stays longer than 68 and 38 days, respectively for the examples above, but are unusual.

France

In France, dialysis for in-patients with acute renal failure is reimbursed under the tarification à l’activité (T2A, DRG tariff) prospective payment system in one of two ways.

If renal dialysis is performed during a stay with a principal diagnosis related to renal insufficiency, the stay is reimbursed according to the groupe homogène de séjour (GHS) related to the groupe homogène de maladie (GHM) 11K02x “Renal insufficiency with dialysis” (where x is a level of severity from 1- 4 or T (très courte durée, very short stay usually < 48 hours). Reimbursement for GHM11K02 ranges from €2,139 to €13,496 (level 1 to 4) or €604 (level T) in public sector hospitals, and from €1,727 to €6,978 (level 1 to 4) or €593 (level T) in the private sector hospitals. In a private sector hospital, physician fees for procedures are paid in addition to the GHM payment.

If dialysis is performed during a stay coded to a principal diagnosis which is not related to renal insufficiency (that is, renal insufficiency is a comorbidity or a complication), renal dialysis is paid on the basis of the procedure. If the patient is treated in a public sector hospital, this payment goes to the hospital; if it is in a private sector hospital, payment goes to the physician. The patient stay in this scenario is classified according to the principal diagnosis and reimbursed according to the relevant GHS with the dialysis reimbursed as a supplement according to the type of dialysis performed. There are several codes for renal dialysis for acute renal failure paid between €113 (for peritoneal dialysis) and €206 (for haemofiltration in new-born) per session. These tariffs are augmented, if relevant, with an intensive care supplement (level A €96 or B €160).

No changes specific to acute renal dialysis are currently anticipated in France.

Germany

In Germany, renal dialysis for acute renal failure is usually reimbursed on the basis of G-DRGs (Diagnosis Related Groups, German version). Hospitals receive a fixed DRG fee (lump sum payment) for an in-patient episode which is intended to cover the total cost of the corresponding hospital stay, largely independent of actual hospital costs.

Due to the fact that acute kidney injury (ICD-10 code N17.-) occurs in many conditions and diseases, related treatment procedures map to a variety of different DRGs and hence, reimbursement rates. Typical G-DRG allocations for acute kidney injury treatments include L71Z (“Renal insufficiency, one day of hospital stay with dialysis) or L60 (“Renal insufficiency”) with hospital reimbursement in the range of €3,000 to €11,000 depending on other factors such as patient age or severity of comorbidities. A case of an acute kidney injury patient without severe comorbidities receiving intermittent hemodialysis (OPS code 8-854.2) and a > 1 day of hospital stay will, for instance, trigger L60B resulting in an average reimbursement of €7,671.

In cases where acute kidney injury is not the principal diagnosis, acute hemodialysis procedures are reimbursed in addition to the applicable DRG as supplemental payment (Zusatzentgelte).

In 2015 the coding of acute kidney injury (N17.-) in the German ICD-10 diagnoses catalogue has been adapted to different degrees of severity. To what extent those adaptions will result in changes in the 2016 DRG allocation and reimbursement is still unclear.

Italy

In Italy, hospital procedures are reimbursed under a DRG system based on ICD-9-CM diagnosis and procedure codes. Generally, the DRG tariffs are all-in, covering medicines, personnel, devices, and procedures, including dialysis. In contrast to the position set out above for England the cost of any type of dialysis performed during an in-patient stay for acute renal failure are included in the DRG tariff applying to the episode of care.

The Italian healthcare system is highly regionalized. DRG tariffs often vary from one Region to another. However, national benchmark tariffs are in place for inpatient procedures delivered by public and accredited private hospitals. Regions can adopt the national tariffs or alter them.

A primary diagnosis of acute renal failure typically maps to DRG 316 (Renal failure) for which the tariff established at the national level is currently around €3700. DRG 316 is listed among the 60 more frequent DRGs recorded for ordinary hospital stays and accounts an average of about 70,000 discharges per year with a mean length of stay around 9.6 days. The most common dialysis procedure recorded under this DRG is haemodialysis.

Patients with acute renal failure are generally managed in general medicine, although nephrology, urology, geriatric, and intensive care specialists may also be involved.

Italy also has a dedicated DRG code (DRG 317, Renal dialysis), which applies only if the patient is hospitalized specifically for the purposes of receiving renal dialysis treatment. The national benchmark tariff for DRG 317 is currently €1,380.

No changes specific to acute renal dialysis are currently anticipated in Italy.

Table 1: Summary Of the Reimbursement Scene For Dialysis In Acute Kidney Injury (AKI) In England, France, Germany, And Italy

Country	Included in fixed tariff for a hospital stay with a diagnosis of AKI?	Included in fixed tariff for a hospital stay with a diagnosis other than AKI?
England	No. Dialysis for AKI is paid in addition to any tariff which applies to the stay. Tariffs for dialysis are fixed, but are among the minority that are negotiated and fixed locally. Some have national published benchmark (‘non-mandatory’) tariffs, some not	No. Dialysis is paid in addition to any tariff applying to the stay.
France	Yes	No. Dialysis is paid in addition to any tariff applying to the stay.
Germany	Yes	No
Italy	Yes. However, there is a tariff for dialysis if this is the specific reason for admitting to the patient.	Yes. However, there is a tariff for dialysis if this is the specific reason for admitting to the patient.

Table 1 above summarizes the acute renal dialysis reimbursement situation in four key EU markets (England, Germany, France, Italy). As the table shows, England is atypical in adding the cost of dialysis to the (fixed) tariff which relates to the hospital stay as a whole. Italy is atypical in including dialysis in the fixed tariff for a hospital stay both for diagnoses of acute kidney injury or something else. Otherwise, as one might expect, dialysis is included in the tariff when the principal diagnosis is acute kidney injury, and not otherwise. In principle, however, the prices are fixed for ‘dialysis’ and fixed for ‘other costs’, effectively creating an overall fixed tariff for a stay which involves dialysis even though this may be made up of two elements. In those situations where dialysis is not separately reimbursed, the system incentivizes hospitals not to dialyse patients suffering acute kidney injury, though this may in practice not be a significant effect.

The situation described here for acute kidney injury is more similar than many situations. It is essential to look closely at the details of how reimbursement rules impact on your business proposition, so that you can adapt your business proposition so that as far as possible it runs with the grain of the system.