Hospital.Help

Berlin – The hospital landscape in Germany is being comprehensively reformed. The Federal Council approved the Hospital Care Improvement Act (KHVVG) today and did not call the Mediation Committee. The decision led to warnings from those involved in the healthcare system.

The reform is intended to significantly reduce the number of current 1,900 clinic locations – including psychiatric and psychosomatic clinics – while providing higher quality and better financing. The core is a new compensation system.

In the future, the flat rate per case should only make up 40 percent of the remuneration. The remaining 60 percent should be given to clinics to provide staff, rooms or necessary medical technology.

In structurally weaker regions, necessary hospitals should be maintained and receive special funding. There should also be the possibility of cross-sector and integrated health centers. There are also changes in staffing and bureaucracy. A transformation fund of 50 billion euros is planned to finance the entire reform – from the federal and state governments.

Critics had always complained about false incentives and guidelines that were too rigid. Many countries fear clinic closures, especially in rural areas, and would urgently like to see further improvements.

Still a lot to do

Klaus Reinhardt, President of the German Medical Association (BÄK), made it clear that the tasks of the federal and state governments are “far from being” completed. There are still “numerous empty spaces” that will have to be closed in the next few weeks and months.

“The reform can only succeed if the federal government works together with the states and listens more closely to the advice from practice than before,” said Reinhardt. This applies to the concrete implementation of the law that has now been passed, but also to necessary legal improvements that must come in the new legislative period.

From the perspective of the German Medical Association, the parliamentary procedure had already brought about improvements in some areas, for example with regard to the consideration of further medical training or medical staffing. These aspects are essential because staffing is the linchpin for high-quality patient care, says Reinhardt.

From his point of view, the first thing to do is to adapt the performance group system quickly and in a fact-oriented manner. In addition, quick solutions are needed on how continuing medical education can be secured under the changed conditions. To do this, financing would have to be secured and better labor law conditions for further training associations would have to be created, explained Reinhardt.

He emphasizes that the retention remuneration also needs to be further developed, as in its current form it “neither achieves the goal of working capital financing that is independent of the number of cases nor a substantial replacement of the DRG remuneration system”.

The false incentives of the diagnosis-related flat rate system must be corrected in order to give hospitals in need of care a stable economic basis for patient care that meets their needs. Last but not least, a reliable and transparently available impact tool is essential for targeted adjustments to the reform components, which will have to be developed in the coming weeks and months.

In order to give hospitals and their employees the urgently needed planning security, the Federal Medical Association believes that the federal and state governments must work in a fact-oriented manner on implementation and the necessary legal regulations in the next few months, despite the election campaign and the formation of a government.

Where legal adjustments are necessary, a new government must implement them promptly. This is the only way hospital care can be made future-proof and sustainable for the benefit of patients and hospital employees.”

The Hartmannbund appeals to everyone involved to act with a sense of proportion when implementing the law and to take into account the legitimate, constructive objections – not just from many federal states – and, above all, not to lose sight of the basic needs of the population. “Unconditional political pragmatism is now required here – especially with a view to the planning security of hospitals and municipalities, but also of the states.”

Susanne Johna, first chairwoman of the Marburger Bund, sees light and shadow. “Many of the announced goals will not be achieved at all or will only be partially achieved,” she said. This is also due to how the reform process has unfolded over the past two years. More cooperation between the federal and state governments would undoubtedly have opened up the opportunity to find practical solutions that take the necessary security of supply into account.

She emphasized that the result now available “still has to pass the reality test”. Obvious deficits would have to be eliminated and bureaucracy reduced in the new legislative period. “We will pay particular attention to this when the new federal government comes into office after the elections next year,” said Johna.

On the plus side, the refinancing of the collective wage increases, which is anchored in the law, can undoubtedly be recorded. “Our greatest concern, however, is that the politically desired reduction in capacity will no longer ensure that there are sufficient supply options in times of crisis in the sense of an urgently needed resilience strategy for the healthcare system.”

Important message for social challenges

“Germany has shown that it can reform even in the extremely difficult environment of the healthcare system. This is very, very important news for the social challenges of the future,” said Christian Karagiannidis, member of the government commission for modern and needs-based hospital care.

The senior physician and head of the ECMO center as well as a specialist in internal medicine, pulmonology and intensive care medicine at the Cologne-Merheim Clinic assumes that the reform will gradually increase the quality of care through centralization and less casual care. According to Karagiannidis, it is a very important step forward for patient safety and quality, especially in cancer medicine.

“In the short term, there won’t be much impact on patient care. “This requires a lot of structural adjustments, which take time,” emphasized Boris Augurzky, RWI Leibniz Institute for Economic Research, and member of the government commission for modern and needs-based hospital care.

Augurzky assumes that in the future after the Federal Council’s decision there will be a greater focus, “particularly in specialized services such as oncology and endoprosthetics.”

“There will be legal regulations on the new performance groups to be introduced next year. Some technical details of the new remuneration system, which is based on these performance groups, also still need to be clarified. The most important task, however, will be to adapt hospital capacities in the regions to the new target. This requires investments and personnel changes.”

“There is now a little more money immediately, which will also help the hospitals in the short term,” explained Reinhard Busse, Technical University of Berlin, member of the advisory board of the Federal Ministry of Health and currently a member of the government commission for modern and needs-based hospital care.

However, the focus is by far on the perspective changes through more precise allocation of the range of services based on minimum requirements for personnel and technical equipment per service group as well as the reserve funding, which is also based on service groups.

“If the service group allocation is implemented by the federal states as provided for in the law, the intended transformation of the hospital landscape will actually occur,” said Busse. He expects the effects to be less unnecessary inpatient treatment, but better quality for the patients who should receive inpatient care, among other things through more staff per remaining case, but also stability for the redesigned hospital sector.

Criticism from the clinics

“With their decision, the federal states have missed the last chance for a good hospital reform with cross-party consensus in this legislative period,” said Gerald Gaß, CEO of the German Hospital Association (DKG). The law will have the opposite effect of what its cumbersome name promises.

Gaß assumes that the supply in Germany will not improve, but will often worsen. He believes that this will even disappear completely in some regions. “The political dispute over the right path will continue well into the coming year. Practically nothing has been gained with this decision, the economic hardship and uncertainty for the clinics remains.”

The DKG boss called on a new federal government to make a radical new start in the health department in order to be able to immediately improve this “unsuitable reform law” at the beginning of the legislative period.

The German Caritas Association and the Catholic Hospital Association were also disappointed. “The Caritas Association is very concerned that the commitment of many Catholic organizations in the hospital sector is seriously at risk, because neither religious orders nor Caritas foundations or other non-profit organizations can remain permanently in the red without going bankrupt,” said Association President Eva Maria Welskop-Deffaa.

Private health insurance also complains that the law has not been corrected. “Unfortunately, the Federal Council has decided against the necessary correction of the hospital reform. The insured are now threatened with a massive increase in costs,” said Florian Reuther, director of the Association of Private Health Insurance.

Paying for investments at their own expense instead of from state tax revenue is also unconstitutional. The planned retention payment based on the motto ‘money without performance’ also threatens to create new deficiencies in care to the detriment of patients.

“Under this law, clinics will be able to increase their income in the future by providing fewer services to patients. A reform can only improve care if hospital fees continue to be based on quality and performance in the future.”

The AOK federal association perceived the vote with relief. The design still needs external dimensions and improvements. But a complete failure of the reform would have been much worse.

“Despite all the shortcomings, the KHVVG is a solid basis for the urgently needed structural reforms to improve the quality of treatment and to provide financial security for the clinics that need it. Because it creates a good framework for defining the performance groups in conjunction with the introduction of sensible reserve financing,” said the CEO of the AOK Federal Association, Carola Reimann.

However, it is not yet clear that the improvements provided for in the law will actually work in practice. Whether the necessary quality-oriented structural change succeeds depends largely on the legal regulations that will have to be negotiated between the Federal Ministry of Health and the states at the beginning of next year.

For example, the service groups and the specific quality requirements for the hospitals should be defined in a binding manner. © may/cmk/kna/dpa/afp/aerzteblatt.de