Hospital Associations Disappointed in German Hospital Reform

After a lengthy debate in Berlin on July 10, Germany’s federal and state governments reached a consensus on a position paper regarding hospital reform. The compromise elicited fierce criticism, however. Representatives from hospital associations labeled it “pointless.” Susanne Johna, MD, PhD, head of the Marburger Bund trade union, considers the compromise “irritating” and “unrealistic.” However, 14 of Germany’s 16 federal states gave their approval. Bavaria was the only state to vote against the position paper. Schleswig-Holstein abstained.

One of the most crucial changes is that the previous system of flat-rate payments is being replaced. Vital clinics are receiving what is known as “contingency rates.” That is, they are continuing to receive money for the services they provide, but not for those that they have provided. “This means that they are receiving a kind of survival guarantee, even if they are offering comparatively few treatments,” says the German Federal Ministry of Health (BMG) on its homepage.

“A Revolution”

“It is a kind of revolution,” commented Karl Lauterbach, MD, PhD, federal minister of Germany for health and member of the Social Democratic Party of Germany (SPD). Bureaucratization and economic pressure are being left behind. Furthermore, agreements being made between physicians on one side and clinic management on the other (which have been required for many interventions to be performed) are a relic of the past, said Lauterbach.

However, no extra money is entering the system as a result of the new allowances. Revenue is just being distributed differently, according to the position paper. The contingency rates should account for 60% of the costs of a procedure; therefore, the proportion from diagnosis-related groups (DRGs) will decrease.

In future, the clinics will have to satisfy certain national quality criteria. According to the position paper, to meet these criteria, the federal states must assign each of their hospitals a service group that is based on their previous case load and severity. In turn, the service groups are a prerequisite for being assigned a contingency rate.

“The small clinics can then concentrate on what they do particularly well — namely, treating the simple cases,” explained Lauterbach. If their quality is sufficient, they can then survive in rural areas, something that is often not possible because of plummeting caseloads. Overall, however, there will be a certain amount of centralization so that patients with particular medical needs can also be treated in large hospitals that are set up for this purpose.

The position paper gives special attention to the cross-sector level-1i facilities with integrated inpatient/outpatient care. These facilities can be regional health centers or other inpatient/outpatient facilities. They should ensure outpatient care close to home for the population and could arise, for example, from the conversion of smaller hospitals.

The whole reform is seen as a “transparency offensive,” said Lauterbach. The federal government now needs to raise the quality of the clinics — a task that it wants to do without the help of the state governments. After the summer recess, the federal government aims to submit a separate act on transparency. According to this act, patients would have the right to know which hospital provides which services at what quality, said the BMG. The “transparency offensive” is set to start on January 1, 2024.

“Pointless” and “Irritating”

Uwe Zimmer, managing director of the Bremen Hospital Association, told the Medscape German Edition that the consensus is a “pointless document,” because the hospitals’ core problems have neither been addressed nor resolved. The hospitals require more money to keep operating. “How we are meant to be paid after the next salary increase was not discussed by the government at any level,” Zimmer continued. The restructuring of something in 3 years’ time is of no interest to anyone today. “Hospitals in the area are close to disappearing!” warned Zimmer.

For Johna, the planned hospital reform is “an invoice with many unknowns.” For instance, it is unclear what effect the planned financial reform and restructuring of the hospital landscape will have on the provision of care. “We cannot afford to go into this blind,” said Johna.

She referred to the concept as “unrealistic” and “really very irritating,” since “you cannot train physicians on a large scale in facilities that have an extremely limited range of services.” Under these circumstances, the medical associations would no longer be able to decide for themselves on the scope and duration of individual segments of further training, Johna said. Finally, effective debureaucratization is missing, said Johna. The central goal has become “a paper tiger upon closer inspection.” A few letters of intent and audit mandates will not be enough.

The National Association of Statutory Health Association Physicians (KBV) argues that the 1i-hospitals will potentially lack staff. “Who is going to provide these services?” asked Andreas Gassen, MD, PhD, chair of the KBV. “The interesting question will be whether it is possible to recruit enough staff. Of course, private primary care physicians and specialists, who would have to perform this work in addition to their work at the practice, could be involved. The framework conditions will be decisive here as to whether colleagues participate or not.”

This article was translated from the Medscape German Edition.

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