>> In her welcoming speech, Minister Nonnemacher described the problems of an aging society, especially in rural areas with a growing structural deficit in more distant regions. The aim here is to ensure care in rural areas and to proceed “courageously and across sectors” when it comes to hospital planning in the narrower sense. According to the Brandenburg Health Minister, this not only includes the further development of primary care hospitals to provide outpatient, inpatient care, but also ensuring a reliable initial diagnosis close to home is an important element. The model project in Templin is gaining valuable experience in all of these facets. Such as the “Innovative Health Care in Brandenburg” project, which has launched essential measures for an outpatient and inpatient center over the past four years.
For Nonnemacher, this also includes the reorganization of acute and emergency care with a triage, an on-call service practice and a monitoring unit. Outpatient consultation hours and treatment paths have also been set up with the most important partners, the doctors in the Templin middle area. Also
Local doctors would have joined the network
“Healthy in Templin” plant merged
in order to work together on health care. However, in the future it will
There would not be fewer medical services, rather services from the inpatient
nary to the outpatient area.
The Brandenburg state government had already provided for this in its coalition agreement by not only committing to further developing the rural primary care hospitals into modern outpatient and inpatient health centers, but also specifically committed to the continued existence of the Templin health center and also implementing comparable approaches to support other regions. In her welcoming message, Nonnemacher was convinced that the Templin outpatient-inpatient center, which was created at the end of the IGiB StimMT project, can “serve as a blueprint” here. The knowledge gained from the project and the methods used would also enable transferability to other regions and hospitals with a comparable setting. But the minister also knows that even with sufficient financial resources and organizational skills it is not enough. Nonnemacher: “You also need the courage to overcome resistance and the willingness to rethink care and take new paths. I wish us all a lot of strength in this.”
What is needs-based
medical care?
This list of interlocking and interdependent measures - taken from the political macro level - makes it clear how complex the management of such a large-scale project is. Nobody knows what lies behind it better than Lutz O. Freiberg, the managing director of IGiB StimMT gGmbH, which, as consortium leader, started the innovation fund project with the serial number 0001 - with the associated license for better care, so to speak - four years ago since then. According to Freiberg, the major project for structural migration in Templin in the Uckermark district of Brandenburg is about nothing less than the fundamental question of what “needs-based medical care in rural regions can look like in the future, taking into account demographic developments and the burden of disease”.
To do this, the question would have to be answered as to which people live in a region and also what needs they actually have? How are they currently being cared for? And: How can you care for them using suitable instruments on an outpatient basis before an inpatient one, and also close to home before away from home?
According to Freiberg, this also includes support services such as telemedicine, but above all better care with the available resources, but allocated differently than in the classic sectoral current care situation, which can often be found in Germany. Freiberg: “But an outpatient-inpatient center is more than a hospital and a medical care center; you have to be prepared to think and develop outpatient and inpatient care together.”
An “accent shift”
This is exactly what describes the basic idea behind structural migration, exemplified by the example of the central area of Templin: outpatient care. According to workshop leader Harald Möhlmann, advisor to the board of AOK Nordost, this is a “shift in emphasis towards priority outpatient care”. As an economist, immediately after the urgent clarification of the quality of care, the question of its economic dimensions arises
Emphasis shift. The basic question of ecological
nomic dimensions can be seen immediately: if you look at the costs of the
care in a coordinate system, it shows that a constant increase in inpatient care is accompanied by a disproportionate increase in the associated costs (blue curve); This is also the case with a constant increase in outpatient care (red curve). From these rather trivial connections, when the two individual curves are added to the costs of the supply mix (green curve), it becomes clear that “there is a point at which the supply mix is optimal”. Since quite a few voices would rate the current supply mix as suboptimal, the great art is to shift the point of today's supply mix; namely towards the optimum, which is probably “a little more in the direction of increasing the proportion of outpatient care” - this way care can be improved through “outpatientization”.
Based on this alone, it's quite obvious
Möhlmann's clear choice of words makes it clear that the shift in the supply mix to be carried out here is anything but
as trivial, because it has to be “done”
be worked out together.” Möhlmann: “By
This development then brings you straight into the economic dimensions that the improvement of care through outpatient care triggers for hospitals, private practitioners and many other people involved in care.”
The long way to long term
needs-based structures
One of these main participants is Christian Quack, managing director of Sana Kliniken Berlin-Brandenburg GmbH, whose group, as he explained in his presentation, has owned a small and “highly deficit standard care hospital” in Templin for many years, which is part of the Innova-
tion fund project acts as the nucleus of the outpatient and inpatient center. According to Quack, “regardless of sponsorship and economics”, if the house has to fulfill a supply mandate set by the federal state, needs-based structures must be created in the long term.
In general, a high outpatient potential was analyzed in the area of Brandenburg before the project began in 2016. This is due, on the one hand, to a demonstrable shortage of skilled workers in the area of health care, coupled with a decline in population and an aging society in this region, which lead to lower inpatient occupancy, which in turn creates deficits due to high maintenance costs.
Nevertheless, such hospitals are important in rural regions because, with their inpatient setting, they are also integrated into outpatient care. Without them, specialist medical care would not be available during non-standard working hours on weekends and at night. Nevertheless, according to Quack, the continued existence of such a house seems to be “increasingly questionable” as the population and thus demand decline. If there were no alternative that focused on “an intersectoral adjustment of offers according to regional demand”.
It may be somewhat surprising that a hospital manager like Quack advocates “strengthening outpatient services” even though he immediately points out that this would only work with an interface and the preservation of the inpatient sector. Quack: “Above all, this requires a coordination office that controls patients so that they receive the care they need in accordance with their needs, in order to ensure basic care close to home while at the same time providing regional emergency care.”
In the Templin project, the so-called outpatient-inpatient center is in the middle. While retaining the inpatient part, there are various outpatient service offerings, both in an emergency and electively through consultation hours and through case and discharge management, which is taken over by a coordination center set up specifically for this purpose. This also includes an emergency
Monitoring by a “Decision Unit” that is intended to ensure that patients can be cared for up to 24 hours a day. For example, pediatric emergency patients are cared for via a telemedicine connection that is available 24 hours a day, 7 days a week with a specialist presence. If further inpatient treatment is necessary, the patient will be transferred to a hospital in Eberswalde, although the following always applies: “outpatient close to home before inpatient”. And it seems to work, much more often than is generally assumed. Quack: “Many of the patients, many of whom would have been cared for as inpatients in the past, can be cared for on an outpatient basis as part of the 'Decision Unit'.” As a result, inpatient cases fell by around 18 percent over a period of three years.
But is it actually in the economic interest of a hospital group to operate on an outpatient basis, contrary to – according to Möhlmann – “the theory that only a full bed is a good bed”? Quack's Solomonic answer: “You have to differentiate between metropolitan areas and large areas with a declining population structure.” Projects like the one in Templin are exactly the right approach here. If – and as is often the case – this is the big but – adequate cost coverage is achieved. In general, outpatient remuneration is significantly lower than inpatient remuneration. According to Quack, this could “only mean adapting the cost structure so that practices can operate in a similar way.”
The legal framework may
Don't limit innovation
The answer from Michael Zaske, head of the health department in the Ministry of Social Affairs, Health, Integration and Consumer Protection in the state of Brandenburg, is quite clear. He said: “In times of a shortage of skilled workers and in times when we have to think about where the budgets are best used, we will not be able to afford to continue to operate several offerings side by side in an unconnected manner in the long term.” also, first of all, to learn that there are approaches to how outpatient and inpatient service provision can be physically thought of together, delivered in one place and how they can be carried out in a qualitatively coordinated manner. But also how - even if they were “very difficult” - to find ways to, if not “put together” the budgets, then at least “think of them together” and – as in pediatric medicine, for example – “inpatiently and to make it permeable on an outpatient basis.”
The Templin project also showed where the need for reform lies at the framework level. Zaske: “The legal framework must not restrict innovation, but rather promote it. That is the heading and the guideline for how we move forward here.” He is not only thinking about joint budgeting, but also regional budgeting, combined with “joint planning” of the necessary services, which follows the need to “ Planning system to be continued to the performance level”. Here we come to the point of what a uniform remuneration for services could look like, with – according to Zaske – an “EBM plus” or a “DRG minus” or something similar; immediately followed by the question of how the “legal framework can be designed so that it does not restrict innovation at this point”. It would be possible to regulate this through a 90b committee at state level, which could assume expanded planning and binding agreement responsibility. This is exactly what is currently being considered by the federal-state committee on cross-sector care under the leadership of the Federal Minister of Health. Unfortunately, the committee took a short break from work on this topic because, understandably, other priorities were set during Corona times.
Nevertheless, Zaske is sure that this topic will be taken up again. Also because “Corona under the magnifying glass” shows what
there is high pressure to innovate in the system. It must be determined at the federal level that there is not only a joint provision of outpatient and inpatient services, but also how this can be determined regionally - regardless of the physical operator. For example, the federal states could, in cooperation with the statutory health insurance associations, determine the regions where such models are fundamentally worth considering. In this context, the topic of innovative health regions could also be sensibly developed further and incorporate some of the ideas from the Templin project. Zaske: “The topic will play a major role in the nationwide debate before and after the next federal election.”
The logic of supply
understand and recognize
If you want that, however, you have to know where such outpatient care actually makes sense. Again, Dr. knows this. Dominik von Stillfried, the chairman of the Central Institute for Statutory Health Insurance (Zi), is very precise. In order to exploit possible outpatient potential, one must first understand the logic of care and recognize that inpatient and outpatient care work like communicating tubes.
In general, high inpatient utilization is an indicator of high or
low performance expenditure. For example, in advance of the IGiB project, the Zi analyzed where such regions can be found in the state of Brandenburg. On the one hand, these are regions in which occupancy days are significantly disproportionate compared to the national average, such as in the Ostprignitz region, where occupancy days are around 40 percent above the national average. According to von Stillfried, in the Prignitz region it is almost 30 percent and in the Uckermark around 25 percent, as well as in Frankfurt (Oder), the Oder-Spree region and the city of Brandenburg. In other words: Outpatient potential cannot be found everywhere in Brandenburg. The Potsdam-Mittelmark and Cottbus regions, for example, are below the national average, which is why it is worth “focusing on certain regions”. This now applies not only to the state of Brandenburg, but also at the federal level. From Stillfried: “If we want to somehow get the problem under control due to increasing health care costs due to demographics alone, we have to exploit outpatient potential as a counterbalance.”
However, high inpatient utilization is only one possible indicator: true outpatient potential can only exist when an (age-standardized) inpatient utilization level is matched by a low outpatient utilization level. To do this, the Zi plotted the standardized outpatient service requirements per district in a coordinate system on the x-axis and displayed the days of occupancy in the hospital on the y-axis. From Stillfried: “This results in conditions.” Such as in the Ostprignitz region, which is already emerging as a problem area when it comes to inpatient occupancy days – almost at the top nationwide.
However, according to von Stillfried, the view of low outpatient and high inpatient care levels, which suggest a generally “strong outpatient potential”, needs to be expanded. Namely, knowledge about all those services that are normally provided in an inpatient setting, but which could also be relocated to the outpatient area if necessary. These quite complex processes describe so-called “outpatient-sensitive conditions”, to which Prof. Dr. Leonie Sundmacher published a meaningful catalog for Germany five years ago in a project funded by Zi, in which all those indications were described that “with good outpatient treatment do not need to be treated much or only rarely in hospital”. In this work, Sundmacher also estimated what proportion of the inpatient cases actually observed could possibly be avoided. For common indications such as ischemic heart disease and heart failure - according to Stillfried - around "two thirds to three quarters of today's cases are viewed as potentially preventable if appropriate outpatient care is available".
This is underlined by a study carried out by the IGES Institute on behalf of Zi. It was found here that 80, 90 and even 95 percent of diagnostic and non-surgical measures take place in hospitals, a large proportion of which could also be provided on an outpatient basis. If you now look at the distribution of these ASK cases in Brandenburg in the IGES report, the already known problem regions appear again: Ostprignitz, Prignitz, Uckermark, supplemented by the region
Elbe magpie. “This also suggests that there is actually an outpatient care deficit here that could be addressed by reducing inpatient cases,” said von Stillfried.
In order to better quantify the special outpatient care needs and to provide better information on where and how to invest in the outpatient sector, a separate Zi analysis for the project in Templin found that there is a high need for cardiological care in Templin, for example . This was represented by the pacemaker control indicator, which is a third higher than the national average and almost three times higher than in German best practice regions such as Baden-Württemberg, which – according to Stillfried – “already has a lot of outpatient potential in Germany have fully exploited it.”
How can the economic potential of outpatient care be quantified? Von Stillfried's answer: "If we were to bring care in Brandenburg to the outpatient and inpatient level that is the national average, we would have a potential savings volume of around 125 million euros." However, if one were to take the level of the best practice region of Baden -Württemberg it would be almost three times as much, which means nothing other than that there is definitely “clear economic savings potential” that would also justify certain investments in the outpatient sector. But also joint capacity planning and hospital budget negotiations, which, according to von Stillfried, “actually has the mandate to advance outpatient care,” including uniform remuneration for outpatient services. <<
by: MVF editor-in-chief Peter Stegmaier