Hospital.Help

Berlin – The government commission for modern and needs-based hospital care today presented a series of recommendations with which, in particular, the sector boundaries between the inpatient and outpatient sectors are to be overcome.

In addition to joint planning for both areas, this includes, among other things, the development of level 1i hospitals – in the hospital reform bill these are called cross-sector care facilities – the development of a primary doctor system and the introduction of regional budgets.

The commission’s tenth statement, which is entitled “Overcoming the sector boundaries of the German health system”, was handed over by its head Tom Bschor to Federal Health Minister Karl Lauterbach (SPD) in Berlin today.

“The sectoral separations – in particular the outpatient-inpatient sector separation – create significant mismanagement and other problems, some of which have been identified for decades,” the statement says.

“The sector boundaries are deeply rooted in the health system and are a main reason for inefficiency.” For reform approaches, the most relevant treatments are those that can be provided on an outpatient basis instead of full, part-time or day inpatient care and are therefore in principle open to service providers in the two (previous) sectors.

“If we do not break down the sector boundaries, we will not be able to provide the baby boomer generation with the number of skilled workers we now have in the health system,” emphasized Lauterbach.

“For the 1,720 hospitals in Germany, we neither have enough doctors and nurses nor the economic conditions or medical needs. Today’s structures are in no way sustainable. We need to use medical staff more efficiently.”

Urgent need for reform

“The need for reform has become so urgent that we can no longer avoid a general overhaul of the German healthcare system,” emphasized Bschor. The background is particularly the shortage of skilled workers. “This year 1.4 million people are celebrating their 60th birthday,” said Bschor – but only 800,000 people are celebrating their 20th birthday.

“If we really want to overcome the sector separation, we have to plan the outpatient and inpatient areas together,” Bschor continued. “This means we can start with the level 1i hospitals, which can be planned regionally.”

You can then see, for example, that there is good coverage of practicing cardiologists in a region, but perhaps not good coverage of urologists. The specialty of urology could then be increasingly represented in hospitals.

In this context, Lauterbach emphasized that politicians do not want to attack resident specialists in any way. It’s just a matter of creating the possibility for resident specialists to work in hospitals in regions where there are not enough specialists to ensure both inpatient and outpatient care. “We are currently examining whether it is possible to introduce a hybrid doctor who can work both in the hospital and as a contract doctor,” said the minister.

Quality specifications for the level 1i clinics

In its report, the government commission makes recommendations that can be implemented in the short term and recommendations for long-term implementation. In the short term, the Level 1i hospitals could be built, which the commission had already described in its third report.

These hospitals should therefore be able to provide both outpatient and inpatient services in order to ensure regionally flexible and integrated health care.

In order to prevent Level 1i hospitals from carrying out complex treatments, the Commission proposes that the self-governing partners draw up a positive list of the treatments that a Level 1i hospital is allowed to carry out.

“To ensure the quality of treatment, personnel and other structural quality specifications for level 1i hospitals should be developed by self-governing partners, for example in the Federal Joint Committee,” the statement continues.

Institute outpatient clinics and affiliated doctors

In addition, the commission outlines in detail how it envisages the future set-up of level 1i hospitals. These should primarily offer outpatient treatment, bill based on daily flat rates and be planned by the federal states. If there is a shortage of care in a region, they should bill outpatient services to the statutory health insurance associations (KVen).

They should negotiate budgets with the KVs in order to regulate remuneration as outpatient services for treatments that were previously provided as inpatients, even in areas that are not underserved. The locations of the Level 1i hospitals should also provide space for other health services such as pharmacies, doctor’s offices, medical care centers, health kiosks, medical supply stores or other health professions.

The measures to be implemented in the short term also include the establishment of institute outpatient clinics, the further development of the hybrid DRG and the expansion of the affiliated doctor system. The commission recommends expanding the possibility of institute outpatient clinics based on the model of psychiatric institute outpatient clinics to other subjects, as these offer a proven opportunity for cross-sector care and now make a relevant contribution to outpatient care in the disciplines of psychiatry and child and adolescent psychiatry.

“In order to overcome sector boundaries from both directions, the affiliated doctor system, which has become increasingly less important in recent years, needs to be strengthened, that is, with the participation of the Federal Association of Affiliated Doctors and Affiliated Hospitals and other competent associations and institutions, hurdles should be identified and then reduced and incentives created,” the statement says.

Dismantle the “double specialist track”.

The medium and long-term measures include the establishment of regional committees under the state chairmanship, which plan outpatient and inpatient care together, and the establishment of a primary doctor system consisting of general practitioners, internists, pediatricians, gynecologists and psychiatrists who control health care and the “double specialist track”. “should be dismantled.

In the medium to long term, comprehensive care by qualified nursing staff with extensive skills – including a restriction on the doctor’s appointment – should also be implemented and regional budgets should be introduced.

“The joint planning of outpatient and inpatient care by a regional planning committee makes sense for all regions and hospitals of all levels, as truly overcoming sector boundaries is linked to cross-sector harmonized planning,” says the statement.

As a future model, the government commission recommends, analogous to the expanded state committees, creating committees with equal representation that plan outpatient and inpatient care in a federal state or region across sectors.

Finally, the Commission states that there are already numerous special regulations in Book V of the Social Security Code that are intended to soften sector boundaries. “What they essentially have in common is that they have not led to a fundamental overcoming of the sector problem,” said the commission.

In addition, the practical implementation of most regulations is made very difficult by legal, bureaucratic and organizational hurdles. “In the medium term, we want to move away from having special regulations in order to overcome sector boundaries,” said Bschor.

Lauterbach explained that the BMG would examine “whether we should incorporate the government commission’s recommendations into the hospital reform or the health care law in the short term.” The minister expects that hospital reform will be placed on the cabinet agenda on May 15th.

The BMG is currently in close coordination with the Federal Minister of Justice on hospital reform. “We want to be absolutely sure that the law does not require approval in the Federal Council,” said Lauterbach. That is why it is currently being examined closely. He made it clear again that he did not want an opening clause in the reform that would allow the states to circumvent the nationwide uniform quality requirements. © fos/aerzteblatt.de