Berlin Minister of Health Karl Lauterbach had announced his hospital reform as a “revolution in the system” – but before the talks with the federal states scheduled for Tuesday, there is growing concern that not much will remain of this revolution.
The reason for this are key points from the ministry that have become known in advance. They contain some generous concessions to the federal states and clinic operators, but cannot eliminate criticism of the reform – or even reinforce it.
The current proposals would not prevent a cold structural change and numerous hospital closures, said the head of the German Hospital Society (DKG), Gerald Gass, on Monday. “In addition to a number of technical discrepancies, the federal concept lacks an answer to the galloping inflation and the development of deficits in hospitals,” emphasized Gass.
The DKG has been insisting on inflation compensation for months and fears an unprecedented wave of bankruptcies in hospitals this year due to the increased costs. Lauterbach also assumes that around a third of the institutions are at risk of insolvency.
In April, the federal government therefore decided to pay out part of the promised energy aid directly. From the point of view of clinic operators, however, the money is not enough.
Hospital planning should remain with the federal states
In a recent conference of health ministers, the federal states also called for short-term inflation compensation – and significantly more say in hospital reform. Lauterbach is dependent on the approval of the federal states for its reform, since they are also responsible for hospital planning and for investments in the houses.
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The new cornerstones therefore accommodate the federal states in a number of important points. Hospital planning remains exclusively with the federal states, it is emphasized in several places. According to the health economist Boris Augurzky from the RWI Leibniz Institute for Economic Research, the federal states were given “more leeway than originally planned”.
Lauterbach’s original plan was to classify all hospitals in Germany into three specific levels and to finance them from there. To do this, the clinics would have to meet certain criteria, for example for operations, in order to be able to settle them with the health insurers, for example with regard to staff and medical equipment. “This coupling should serve as an important lever for concentrating hospital capacities,” Augurzky told Handelsblatt.
Among other things, the reform was intended to prevent smaller clinics from performing complicated procedures while, at the same time, many clinics in cities offer the same operations. The Federal Republic affords more hospital places per citizen than any other country in the EU and is also at the top when it comes to the number of cases.
However, the cornerstones now stipulate that nationwide levels should only ensure “greater transparency” about the supply. However, the principle of the three levels should no longer be a criterion for financing. Instead, the services of a hospital should be used. That would give the countries greater freedom in planning. A similar model is currently being planned in North Rhine-Westphalia.
“Consistent structuring or qualitative patchwork”
In practice, this would mean that – if the countries intend to – clinics can take on treatments that they should not have taken on in the level model. The only requirement is that they comply with the quality specifications. In this way, some houses could keep income that they should actually forego.
The services provided by the hospitals, defined in technical jargon as service groups, should also become the decisive criterion for allocating the provision flat rate, which is intended to supplement the current case flat rate system (Diagnosis Related Group, DRG) from 2025. Through the DRG, clinics receive money per patient and diagnosis.
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Criteria such as quality, treatment time or success play a subordinate role. Lauterbach sees this as an incentive for “cheap medicine” and wants to supplement the DRG with fixed amounts that clinics receive.
Unfortunately, it seems that the levels are downgraded to a pure transparency model without structuring the hospital landscape. A spokesman for the Central Association of Statutory Health Insurance (GKV)
“It is all the more important that the advance financing is designed in such a way that the federal states have the incentive to bundle service groups at a few locations,” said Augurzky. In the Central Association of Statutory Health Insurance (GKV), given the lower importance of the levels for hospitals, there is even concern that the reform could fizzle out.
“Unfortunately, it seems that the levels are downgraded to a pure transparency model without structuring the hospital landscape,” said a spokesman for the Handelsblatt. “The next consultations of the Bund-Länder-AG will give an indication of whether there will be a consistent structuring of the hospital landscape at all or whether the qualitative patchwork will be preserved.”
Financing of the reform still unclear
The chairwoman of the AOK federal association, Carola Reimann, on the other hand, speaks of a “good basis for the reform” – especially because the performance groups are to be defined nationwide. However, the key issues paper for clinics in rural regions provides for states to be granted exceptions to the federal requirements. This would also significantly weaken the original reform.
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The financing of the reform remains completely unclear. Experts estimate the costs to be in the mid-double-digit billions. The cornerstones contain the indication that the federal states are responsible for hospital investments.
The federal states, which should actually finance the investments of the clinics in buildings and large medical technology, have not sufficiently fulfilled their obligations for a long time. How Lauterbach wants to change that is so far unclear.
The key issues paper even promises the federal states additional federal funds via the existing hospital structure fund. “In this respect, the question also arises as to what consideration by the federal states is associated with federal participation in investment financing,” said expert Augurzky.
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