Government commission presents hospital concept
08.12.2022 10:59
In the future, the treatment of patients in hospitals should be based more on medical and less on economic criteria. This is what the 17-member “Government Commission for Modern and Needs-Based Hospital Care” recommends. For this purpose, the clinics should be rewarded according to three new criteria: provision of services, care levels and service groups. The recommendation states that the per-case flat rate system must be further developed accordingly.
Federal Health Minister Prof. Karl Lauterbach explains: “This recommendation will be a basis for our major hospital reform. Patients should be able to rely on the fact that they will receive quick and good care everywhere, even in rural areas, and that medical and not economic reasons determine their treatment. To do this, we have to overcome the per-case flat-rate system. We have pushed the economy too far. Good basic care must be guaranteed for everyone and special interventions must be concentrated in particularly well-equipped clinics. At the moment, mediocrity and quantity are too often rewarded. In the future, quality and appropriateness should be the sole criteria for good care. I would like to thank all the experts in the government commission for their excellent work.”
The government commission's proposals in detail:
1. Remuneration for reserve services
Currently, hospital services are largely financed through flat rates per case (see background below). Fixed costs - such as staffing, an emergency room or necessary medical technology - must also largely be generated through the flat rate per case. In order to underline the importance of hospitals for public services and to reduce the economic pressure on as many cases of treatment as possible, the government commission recommends defining a fixed amount as maintenance costs in the future, which hospitals - depending on their allocation (see points 2 and 3) - receive. This takes economic pressure off hospitals.
2. Definition of hospital care levels (levels)
The hospital structures in Germany have grown historically. Each hospital has different specialist departments and offers different services. In the future, hospitals will be classified into three specific levels and supported accordingly:
1. Basic care – basic medical and nursing care, for example basic surgical procedures and emergencies.
2. Regular and specialized care – hospitals that offer additional services compared to basic care.
3. Maximum care – for example university hospitals.
There should be uniform minimum requirements for each level. This would mean that, for the first time, uniform standards would apply to equipment, space and staffing - and the quality of treatment for patients would be significantly increased.
Level I hospitals are given special importance. They must guarantee nationwide supply close to home. They are therefore divided into hospitals that provide emergency care (Level I n) and those that offer integrated outpatient/inpatient care (Level I i). Level I hospitals should play a key role in overcoming the healthcare system that is still too often separated from inpatient to outpatient. The government commission therefore recommends planning them regionally across sectors, removing them completely from the DRG system and remunerating them via daily flat rates. In addition, appropriate legal changes should make it possible for them to be under nursing supervision.
3. Introduction of defined performance groups
The merely rough allocation of specialist departments (such as “Internal Medicine”) to hospitals should be replaced by more precisely defined service groups (e.g. “Cardiology”). Currently, hospitals treat certain cases too often without appropriate personnel and technical equipment, such as heart attacks without a left heart catheter, strokes without a stroke unit or oncological diseases without a certified cancer center.
In the future, treatments will only be able to be billed if the hospital has been assigned the appropriate service group. The prerequisite for the allocation is the fulfillment of precisely defined structural requirements for the respective performance group, for example with regard to personnel and equipment. Depending on the complexity, it is determined for each service group whether it may be provided at hospitals of all three levels or only at hospitals of higher levels (II and III or only III). This significantly improves the quality of treatment for patients. A reserve share is set for each performance group.
The government commission recommends that the regulations should not be applied immediately, but should be introduced gradually in a generous transition phase (convergence phase of 5 years). This gives hospitals, doctors, health insurance companies and states enough time to adapt to the changed financing system.
Commission of the government commission for modern and needs-based hospital care
According to the coalition agreement, the government commission should present recommendations for the further development of hospital financing, which supplements the current system with a system of revenue-independent retention fees that is differentiated according to care levels (primary, basic, standard, maximum care, university hospitals). The government commission was set up in May 2022 and has since submitted statements on various topics (including adequate financing of pediatrics and obstetrics, hospital day care), which have been implemented in the Hospital Care Relief Act.
Background:
Current hospital financing Hospitals cover their ongoing operating costs (costs for medical treatment, e.g. personnel, surgical requirements, ...) through the so-called flat rates (DRGs). This means: You receive a fixed amount, even if the treatment actually cost more or less. Investment costs – for example costs for buildings or structural maintenance – must be borne by the states in sufficient amounts. This does not happen to a sufficient extent across the board. The per-case flat-rate system creates an incentive to carry out a large number of operations or other treatments - in case of doubt, even unnecessary ones (so-called performance or quantity incentive), and in particular to bill the per-case flat-rates that are particularly lucrative - and specialist areas that are less lucrative, such as Pediatric and adolescent medicine, to close. In addition, there is an economic incentive to discharge patients as early as possible in order to earn more from the flat rate per case than the treatment cost (“bloody discharge”). The economic pressure in the system is correspondingly high. In a global comparison, Germany finances its hospitals most heavily through performance and volume incentives. This means that hospital financing differs not only from other health systems that use flat rates per case, but also from comparable critical infrastructure and public service facilities in Germany (e.g. fire brigade).
Various legislative steps have been taken in the past to mitigate the negative effects of flat rates per case. For example, by defining requirements (e.g. a certain minimum quantity) that hospitals must meet in order to bill for a service or surcharges for certain hospitals (e.g. security surcharges for hospitals that are economically threatened but are important for care) or the Removal of care from the flat rates per case. These solutions “in the system” have not been able to completely resolve the deficits in flat-rate financing per case.