Berlin Health Minister Karl Lauterbach (SPD) was recently able to experience for himself how deep the German hospital landscape is in the crisis. At the beginning of May he visited a children’s clinic in Sankt Augustin in North Rhine-Westphalia.
The structural condition of the clinic was “undignified,” he said. It can’t go on like this. A few days earlier, he had presented the composition of a panel of experts for his hospital reform – a mammoth political task. The most recent large-scale reform dates back 20 years.
The German system with around 1,900 clinics and their almost 500,000 employees is considered expensive, ailing and inefficient. According to the Hospital Rating Report, more than every tenth facility is deep in the red, and in some federal states almost every third clinic is facing bankruptcy. According to the German Hospital Society, 6.3 billion euros would be needed just to maintain the inventory.
This is also made clear by a special report presented on Monday by the Monopolies Commission, which deals with the hospital landscape in detail and was the first body to submit far-reaching reform proposals to the minister. Monopolies Commission head Jürgen Kühling is critical of the current structures. “Neither the clinics, the patients nor the politicians are benefiting from the current situation,” he said in an interview with the Handelsblatt. “It won’t work without reforms.”
Top jobs of the day
Find the best jobs now and
be notified by email.
Kühling is pushing for more competition, clear criteria for clinic closures and new ways of financing. “In the case of public hospitals, the municipalities often have to step in and compensate for deficits year after year, partly to prevent insolvency – without a clear concept,” he said. At the same time, the range of relevant structures in some rural regions is declining. Elsewhere, on the other hand, one clinic follows the other, for example in certain metropolitan areas.
Countries should determine minimum required benefits
In addition, there would be huge false incentives. “Small clinics sometimes offer treatments without coming up with relevant sizes in terms of the number of cases and the necessary quality,” said Kühling. “That’s why the care for the patients is often worse than it should and could be, which indicates that we are not using the funds well and are sometimes given the wrong structures.”
The Monopolies Commission is therefore pushing for clear target parameters that determine what comprehensive care is necessary and what care is better taken care of in specialized centers. The countries that have been planning the needs so far should only set so-called safety limits – i.e. the minimum necessary range of medical services in a certain region.
At the same time, the countries should set upper limits to avoid oversupply. The Monopolies Commission leaves the difficult question of how exactly these limits are defined to politicians, but refers to countries such as North Rhine-Westphalia. There, the nearest clinic for basic care can be reached in no more than 20 minutes, but no longer offers all operations.
The patients, in turn, should receive more transparent and detailed information about the quality and the offer in hospitals than at present, for example from the health insurance companies. The Monopolies Commission speaks of a “quality competition”. Those clinics that are above the limits would receive less or no funding and would either have to adjust their offerings or be closed.
There has long been a discussion about how many clinics are needed in Germany.
(Photo: dpa)
However, the Monopolies Commission makes no statement on the explosive question of how many clinics and beds there are in Germany. “I also think it’s difficult to decide at the desk where there is an oversupply or undersupply,” said Kühling. “Competition must regulate this.” Clinics should only be maintained, for example by receiving a provision fee, if they are needed to ensure care.
Provision flat rates are additional payments that clinics receive if they have certain staff and technology available – and not for the services provided. This would be a departure from the currently applicable flat rate system, which the traffic light parties also intend in the coalition agreement and which is part of the deliberations in the hospital commission convened by Minister Lauterbach.
The flat rate per case sometimes creates huge false incentives, which the Monopolies Commission also criticizes. For example, she ensures that knee surgeries are extremely attractive for hospitals to improve their balance sheets, as they guarantee short stays with high remuneration.
However, according to the recommendation of the Monopolies Commission, the system should not be completely abolished, but rather further developed by a scientific advisory board. Accordingly, Kühling is also critical of Lauterbach’s plans to remove maternity clinics from the system. Many of these clinics are currently threatened with closure due to a lack of cases. Lauterbach’s “emergency brake” does not solve the problem in the long term, criticizes Kühling.
More Handelsblatt articles on the healthcare industry:
The Monopolies Commission proposes yet another reversal in hospital financing. The provision surcharge is to be borne in part or in full by the statutory health insurance, which so far has only financed the operating costs.
The investment costs, on the other hand, are borne by the federal states, which, however, do not fulfill this task sufficiently. If the investment costs were integrated into the flat rate per case, as proposed by the Monopolies Commission, the federal states would no longer be involved, only the statutory health insurance would be involved.
Criticism of this comes from the German Hospital Society (DKG). The proposal was “not appropriate,” said DKG boss Gerald Gass. Overall, the opinion of the Monopolies Commission would breathe an “extremely competitive spirit”. It fails to recognize that health and healthcare are not normal economic goods.
Gearing the range of care more closely to patient demand would almost inevitably lead to the disappearance of certain offers in sparsely populated regions. There is a risk that the proposed Minimum supply limit would become the standard. However, the hospitals shared the view that “Quality competition is an important factor”.
More: Lauterbach at the Doctors’ Day looking for supporters