>> For health policy in the coming legislative period, emergency care is the key point of contact between statutory health care and inpatient care. This is not just where the greatest need for action lies. At this point, the future supply structures in Germany will also be decided. Politicians must now make smart decisions. are necessary
a) the expansion of truly outpatient care structures,
b) the concentration of hospital outpatient clinics, particularly in metropolitan areas and
c) an associated adjustment of dispensable inpatient care capacities.

Why is there an urgent need for action? Not just because hospitals are pushing for better remuneration for outpatients treated in emergency rooms. The real problem is the constantly increasing direct use of outpatient clinics by insured people. This phenomenon cannot be attributed solely to deficits in statutory health care. A look at the international literature shows: The problem exists in all industrialized countries; Measures are being taken everywhere to reduce the direct use of hospitals.1 Australia is trying with humorous films entitled “Keep Emergencies for Emergencies” and initial self-assessments via the Internet. In Sweden, patients can no longer reach the newly built location of the renowned Karolinska Hospital on foot. Emergency rooms should not be “clogged” with trivial cases. In addition, the emergency clinics prove to be a way to occupy inpatient hospital structures that are actually dispensable and thus prevent a necessary structural change.
Despite the demographic aging of the population, hospital cases due to medical admissions in Germany have been falling continuously for years. This is an expression of medical progress, through which the options for outpatient treatment are continually increasing. According to DRG statistics, the number of cases in 2015 (8.9 million) was around 5% lower than in 2009 (9.4 million). Cases with emergency admissions rose by 27% over the same period and contributed to an increase in all hospital cases by 9%. During the same period, the proportion of hospital cases requiring medical admission fell from 55% to 48%. Direct use, standardized according to age and gender, is particularly high in metropolitan areas, i.e. where there is also a good health care structure. It is primarily the younger insured people who tend to make direct use. In this respect, the spectrum of diagnoses for patients treated as outpatients in hospital outpatient clinics differs from that of the contracted medical on-call service. In the former case, infections, injuries, pain predominate, and in the latter, chronic illnesses predominate. The direct use of outpatient treatment rose particularly sharply (14%) in 2013 - after the practice fee was eliminated. All of this points to a change in expectations, for which surveys of patients in emergency rooms provide further evidence.2 Fast, interdisciplinary treatment is expected at any time and, if possible, in one place. The advertising of many hospitals for their emergency departments takes up this and apparently falls on fertile ground.
But: Should this development still be supported politically? As IGES has shown, with advanced substitution of hospital treatment by medical treatment, metropolitan areas in particular have the highest proportion of essentially avoidable hospital cases after admission via emergency departments.3 The admission frequencies are ultimately explained by the available bed density. As early as 2012, the Health Advisory Council recommended taking all measures to reduce avoidable hospital admissions. He estimated the potential for this to be around 40% in all cases and saw the necessary structural adjustment as the necessary efficiency reserve to make the demographic development more tolerable for contributors.
The retirement wave of baby boomers will begin in the coming legislative period. So it’s high time for the necessary structural change. It should be noted that the utilization of hospital outpatient departments is still comparatively low, despite the increasing use. The nationwide billing data for cases treated as outpatients in emergency clinics in 2015 show an average utilization of 0.8 patients per hospital per hour. A current evaluation for the third quarter of 2016 in Hesse (see table) reveals that outpatient clinics in rural areas are below this average. But even in large cities - during practice opening hours - the outpatient clinics only have an average occupancy rate of 1.6 patients per hour. This means that only at peak times, when practices are open, an average of around 4 patients per hour are treated as outpatients. Keeping all of these outpatient clinics open not only requires enormous maintenance costs, as the DGINA report from 2015 explained. On this basis, the German Hospital Association demands that the maintenance costs be covered, neglecting the fact that the hospitals already receive a flat-rate compensation for each hospital case. In December 2016, Prof. Günter Neubauer demonstrated that the current remuneration rates would already be sufficient against this background.4
The real problem is the low average utilization. It increases the financial pressure to admit patients, because inpatient treatment can easily earn 30 to 50 times as much as outpatient treatment. It also makes it more difficult to use portal practices to treat simpler cases. A well-equipped portal practice only makes economic sense when the capacity is at least 5 patients per hour. Especially in metropolitan areas, where there are currently 30 or more hospitals within a 30-minute drive, a corresponding concentration of contact points would be possible without any problems. One example is the Berlin Accident Hospital. According to billing data from KV Berlin, an average of 6 patients per hour were treated in the outpatient clinic in the third quarter of 2016, and around 3 patients per hour in the newly set up portal practice. In addition to the fees for diagnostics, the hospital receives the same revenue as a medium-sized general practice or specialist practice. However, the number of patients treated together can still be increased, especially if the portal practice is expanded. The need for an accurate, rapid initial assessment by non-medical staff also requires practice and routine and argues for a concentration of emergency departments. This would significantly increase the overall quality of emergency care.5 An analysis by Prof. Busse on mortality from heart attacks in Berlin shows that this is necessary.6
What could a solution look like? The statutory health insurance associations establish an initial telephone assessment that is available around the clock and delegates patients to the right place of treatment. On-call practices are set up at the locations of central emergency clinics - including during practice opening hours - and take on around 50% of patients there according to the initial assessment. The health insurance companies are obliged to base the prospective volume agreements for each hospital on the basis of which alternative outpatient and inpatient care options exist locally and where the required minimum quantities are provided. Stationary capacities that are required after this structural change will be reduced within 5 years. In rural regions, small hospital locations would be supplemented by outpatient care centers. Overall, the number of hospitals could be roughly halved. If you follow the AOK's latest hospital report, this would not be a mistake in terms of the staffing situation and the quality of care. <<

literature
1. Van den Heede K, van den Voorde C (2016) Interventions to reduce emergency department utilization: A review of reviews. Health Policy 120; 12: 1337–1349
2. Schmiedhofer, M et al (2016) Patient motives behind low-acuity visits to the emergency department in Germany. BMJ Open. 2016 Nov 16;6(11)
3. Albrecht M et al (2016) Outpatient potential in inpatient emergency care; IGES Berlin
4. Neubauer G (2016) Critical analysis of the “Report on outpatient emergency care in hospitals – case cost calculation and structural analysis”; IfG Munich
5. Geissler A et al (2017) Transforming emergency care. In: Klauber J et al (eds.) Hospital Report 2017, Stuttgart: 41-59
6. Busse R (2015) What should emergency care look like in Berlin and Brandenburg? https://www.mig.tu-berlin.de/fileadmin/a38331600/2015.lectures/Potsdam_2015.11.11.bw-Notfallbedarf2030.pdf

Citation information: doi:10.24945/MVF.02.17.1866-0533.2009