September 10th of this year was a truly special day for the German healthcare system. Shortly after noon, the German Healthcare Management Association (BMC) presented its latest position paper in its online "Spotlight" format, which opened "a new chapter for healthcare" and proposed "sector-independent care with value-based care" (page 42 ff.). Just a few hours later, a scientific symposium marked the retirement of Jürgen Klauber – who had served as Managing Director of the Scientific Institute of the AOK (WidO) for 30 years – focusing on his key topic of "quality of care." While the timing may be purely coincidental, it clearly demonstrates one thing: given the figures, data, and facts presented at this high-level symposium, the problem is not a lack of knowledge, but rather the absence of evidence in far too many political decisions, such as the "Wertheim miracle.".

Professor Dr. Ellen Nolte from the London School of Hygiene & Tropical Medicine opened the presentation with a fact-based overview. She presented a number of international studies, such as the Numbeo Health Care Index (1), the Commonwealth Fund (2), and the OECD publication "Health at a Glance: Europe 2024" (3). She demonstrated that Germany has less of a problem with access to care or equal opportunities, but rather with care processes, outcomes, and especially coordinated care. According to Nolte, all of this leads to a negative conclusion: While Germany, for example, has a five-year net survival rate above the EU average for most types of cancer, the "German system is expensive compared to what it produces." She argued that evaluating quality and performance is essential for achieving better goals and provides important guidance for identifying the strengths and weaknesses of the healthcare system. Nolte: "Performance evaluation can only improve the healthcare system if it is supported by a clear vision and embedded in the governance structures."„
Professor Dr. Reinhard Busse from the Department of Healthcare Management at the Technical University of Berlin was extremely critical of the political situation. In his lecture „Quality Improvement in Inpatient Care: Status and Perspectives of Hospital Reform“ (5), he minced no words. He demanded: „We must be honest about the actual provision of care.“ He was also absolutely opposed to converting loans into grants, because that would „only unnecessarily remove the pressure“ needed to get the system moving. Busse: „We all want to avoid the system completely crashing, but the danger is great.“
Busse, a member of the now-dissolved government commission for modern and needs-based hospital care, underscored this warning with numerous facts, figures, and some rather disturbing observations; disturbing because they made it clear how politics often acts beyond any evidence.

Ad 1: Number of hospital beds
According to Busse, Germany has 501,000 more hospital beds than the EU average. And also 501,000 more than its immediate neighboring countries. The problem, however, is that, according to Busse, hospitals are paid to use the beds. Normally, they receive payment for putting patients in beds, but during the coronavirus pandemic, a different business model emerged, in which hospitals were even paid for empty beds instead of being compensated based on quality.
This mismanagement results in two overlapping problems for the health economist.
Patients are not only distributed among far too many hospitals, but also among many hospitals that are often inadequately equipped. Furthermore, according to Busse, there are cases that are either inappropriate or result in excessively long hospital stays. For example, in Germany, each cancer patient is admitted to a hospital bed an average of 3.5 times, while in the Netherlands, the average is only 1.2 times. Busse: "When it comes to cancer, we see a particularly drastic overuse of inpatient capacity."„
This leads to unnecessary costs and promotes inefficiency. Furthermore, the many patients receiving incorrect care tie up staff unnecessarily. With this, he also put an end to the complaints about a shortage of professional nurses. "In Germany, we have the third-highest number of active nursing staff after Finland and Ireland." But: there are too few nurses where they are truly needed. And also too few doctors, because outside of core working hours they often need more than 30 minutes to reach patients, which in turn leads to unnecessarily poor quality of care.

Ad 2: Structural problems: Necessary cases are too often treated in hospitals with inadequate equipment.
In Germany, according to analyses from the latest quality monitor, patients with heart attacks are treated in 1,200 hospitals. However, only 600 of these hospitals have the capability to perform left heart catheterization, which is used for the precise diagnosis of heart diseases such as coronary artery disease (CAD) or a heart attack. It is evident that the use of this catheterization procedure, or PCI, significantly reduces mortality, recurrent heart attacks, and strokes (from 141 to 81).
At this point, after Busse, the question often arises: But what about the countryside? And the convenient notion that it's better to provide poor services to the local population than not to provide any at all.
To refute this misconception, the economist examined a rural area in Lower Saxony, the Weser-Ems region, and marked hospitals with and without left heart catheterization labs on a map, along with the number of cases treated at each. He then analyzed the distance traveled when an ambulance transport goes not to the very nearest hospital, but to the nearest one with adequate equipment. His unsurprising result: "I didn't find a single hospital location more than 30 km from the nearest hospital with a left heart catheterization lab. It's a complete misconception that people have to receive such poor treatment because the nearest good hospital is too far away."„
The problem identified here, according to Busse, also occurs in the area of stroke: Over 1,000 hospitals treat strokes, but only 354 have certified stroke units. This is despite the well-known and evident fact that survival times are significantly better in stroke units: The 1-year mortality rate is a quarter lower in hospitals with versus without a stroke unit (231,000 deaths per day vs. 301,000 deaths per day). A similar situation exists in the area of cancer, where the WiZen study shows significantly higher survival rates for treatments in cancer centers, with even significant survival advantages of up to 231,000 deaths per day for 11 types of cancer.
And yet, the state of Schleswig-Holstein, where 19 hospitals treat breast cancer patients but only 10 have designated breast cancer centers, is suing the Federal Joint Committee. If the committee had used Brandenburg's figures, the ratio would look even worse, Busse added.
And what about the country again?
Busse focused his analysis on the Berlin/Brandenburg region, where an average of three pancreatic surgeries are performed daily. Despite this, these procedures are carried out in 33 hospitals (including Strausberg since July 1, 2023): 13 in Kaulsdorf, 14 in St. Hedwig, and 17 in Bad Saarow – all this despite a minimum volume of 20 procedures defined by the G-BA (Federal Joint Committee).
Looking ahead to the hospital reform that may eventually come, Busse asks: "How many of them will likely be assigned the service category of pancreatic surgery if a cancer center is not a requirement?" His prediction: "I believe that almost exactly 33 hospitals will be assigned this service category."„

Ad3: The chicken-and-egg problem
His question: „Do we have so many beds because we have so many cases, or so many cases because we have so many beds?” Busse points out that Germany ranks second among OECD countries after Bulgaria in terms of hospitalizations. The total number of hospitalizations is two-thirds higher than the OECD average. In contrast, Switzerland has 251,000 fewer cases, Denmark 401,000 fewer, and the UK and the Netherlands even 501,000 fewer and 601,000 fewer, respectively. His calculation: „If we had the same number of cases as Switzerland, we would have 12.5 million instead of 16.5 million inpatient cases; if we had Denmark, we would have only 10 million.”
Of all the many cases treated as inpatients in German hospitals each year, approximately 11,000 are diagnosed with diabetes. Busse's pointed question: "Why are these patients even hospitalized?" He answered his own question: "Either because there was no outpatient care available, or the outpatient care was so poor that the patients require an amputation as an inpatient." The National Association of Statutory Health Insurance Physicians (KBV) would certainly disagree with this statement, but the question is legitimate: "What are these patients doing in the hospital?" According to Busse, the situation is further complicated by the fact that Germany has significantly higher rates of avoidable, "ambulatory care-sensitive" hospitalizations than any other EU country.
After a discussion of the Hospital Care Improvement Act (KHVVG) and the draft Hospital Adaptation Act (KHAG), in which the care levels originally proposed by the commission with hospital-wide minimum requirements were removed and the service groups were weakened, Busse addressed the present and possible future.
Unfortunately, three years ago, when the Commission had prepared and presented the reform proposal, he had the feeling that "there were politicians who understood what we were proposing".
He no longer believes that.
Here he took a look at the hospital reform in the state of North Rhine-Westphalia. While there is a clear political will to address the main problem – that hospitals too often want to perform unnecessary surgeries – over-treatment persists for some indications, as the old actual number of cases is now the new target. Furthermore, the main problem of too many hospitals with too many beds is not being addressed in North Rhine-Westphalia.
Even worse: In the state of Baden-Württemberg, a hospital that had already gone bankrupt was forced to reopen, a situation the ARD morning news program dubbed the "Miracle of Wertheim." Busse can only shake his head at this: According to him, the Main-Tauber district has four hospitals for 130,000 inhabitants. If this figure were extrapolated nationwide, there would be as many as 2,500 hospitals in Germany.
But now the city of Wertheim has found a private operator who will receive up to €2.75 million per year to cover the deficit. On the morning the ARD "Morgenmagazin" reported on the case, 20 of the 80 available beds were occupied. Extrapolating this to a year, the municipality would have to pay an additional €2,000 per patient on top of what the health insurance companies cover. If this amount were then extrapolated to the national average of 16.5 million hospital cases, the hospital budget would increase by €33 billion.
Regarding quality: The website of the hospital in question states that it claims to have a stroke unit, but it has neither a neurology department nor a CT scanner on-site (only "via a partner practice"). Heart attacks are also explicitly listed as an indication, even though there is no left heart catheterization lab; patients are stabilized and then transferred. Busse: "That's completely against the guidelines, but you can just claim anything on a website." His question: "What about efficiency, what about the quality of care? We'll have to wait and see which performance categories they're assigned."
by: MVF editor-in-chief Peter Stegmaier