>> At the DGIV Federal Congress, many presentations presented the existing structures and framework conditions for care in terms of efficiency and effectiveness reserves, knowing full well that - says Spitzer - "we have known for a long time that the interface between outpatient and inpatient care has the greatest economic potential "Billions of euros could be exploited." He deliberately chooses the subjunctive because some people have already cut their teeth "on overcoming the old-fashioned sector boundaries"; not only because the “chunks that had to be removed seemed too hard and difficult to digest, but also because people were afraid of the effort and “would rather leave these large and complex tasks to the following (government) generations.”
What stood out from the diverse, interesting program of the DGIV Congress were, in addition to the presentations from the first session on “Further development of cross-sector care” – “Digitalization in the German healthcare system – assessments and outlook” by Christian Klose (BMG), the three positions of the National Association of Statutory Health Insurance Funds, of hospitals and doctors for cross-sector care – Dr. Wulf-Dietrich Leber (GKV National Association), Marc Schreiner (BKG) and Dr. Bernhard Gibis (KBV) – particularly those from the second session. Under the meta-theme “In Focus”, top-class professors had their say who, from a scientific perspective, addressed the opportunities and obstacles on the long path to integrated care.
It started with Prof. Dr. Boris Augurzky, head of the health competence area at the Essen economic research institute RWI, with his lecture on “Use of funds from the structural funds – determining the situation and perspectives”. According to session moderator Prof. Dr. Dr. Alfred Holzgreve, Director of Clinical Research and Academic Teaching at Vivantes and Deputy Chairman of the Board of Directors of the DGIV, will be “the lever” with which the structures – especially those of the hospital sector – can be changed in Germany.
This sector is not doing so badly if you follow the figures from the current “Hospital Report 2018” prepared by the RWI, which, however, is based on the 2016 figures. Over time, according to Augurzky, the economic situation of hospitals has improved significantly compared to 2012. While in 2012 33 percent of all hospitals suffered an annual loss, in 2018 it was only 13 percent. However, the hospital landscape is very different. The general rule is that:
• small hospitals perform worse than large ones,
• the specialization is very advantageous economically and especially in terms of patient satisfaction,
• Hospital associations and chains are economically stronger than soloists,
• The economic situation in the south of Germany is worse than in the north and east.

With regard to the last point, the old federal states have a high density of hospitals, while the new federal states in particular, with their significantly lower house density, generally have a good economic situation. Now, according to Augurzky, it can be assumed that the general economic situation of all hospitals has deteriorated significantly since 2017 - and also in the following years. One reason for this is that the number of cases declined in 2017 for the first time since the DRG was introduced, while the length of stay and the number of days of occupancy have been continuously decreasing for years.
The comparatively high hospital density in Germany, which varies greatly from region to region, is now linked to a “somewhat unfavorable demand structure”, which brings us to the topic of integrated care. According to Augurzky, the demand structure in Germany is also rather unfavorable. While Germany has 23.5 hospital cases per 100 inhabitants, all other EU countries (with the exception of Austria) have significantly fewer hospital cases per resident. In Denmark, for example, there would only be 13, in the Netherlands and Iceland only 11.5. This is the case, explains Augurzky, because in these countries “outpatient and inpatient care are always thought of together.” In Germany, however, this is contradicted by the different remuneration models, which “make it difficult for us to think in our heads”.
In this context, according to Augurzky
also the structural funds can be seen. This was set up to optimize the existing structures with a budget of one billion euros - half from the health fund, the other half from funds from the federal states. According to the RWI researcher, it should always be in the self-interest of every hospital to optimize its own structures. The first structural fund was oversubscribed twice: by May 30, 2018, 409 million euros had been approved from the health fund share, but another 400 million would come from tax revenue. Most of this money went to North Rhine-Westphalia (101 million euros), followed by Bavaria (77) and Baden-Württemberg (64). According to Augurzky's findings, 90 percent of these funds are intended for concentration measures, but this can be one of three things: concentration, conversion or closure.
The latter is progressing rather slowly: gross there were just 5,300 fewer beds; gross because some of the beds that were closed and dismantled at one location were rebuilt at another location. This means that only 2,800 net beds and 28 locations were closed. Converted and based on the gross figure, a hospital bed dismantled via the health structural fund costs around 155,000 euros.
But that is only the beginning. A year ago, the RWI calculated what the transition to a target structure would cost in total. According to Augurzky, if Saxony is seen as a model country with regard to its hospital landscape, 11 billion euros would have to be invested in order to optimize the hospital structure in all federal states. In numbers, this means no less than the closure of 286 locations with a total of 26,500 beds. Augurzky: “We have already used one billion euros through the first structural funds, so I would say: ten more would be necessary.”
However, the innovation fund, to which Univ.-Prof. Dr. Holger Pfaff, the elected chairman of the Innovation Fund Committee, gave a presentation and asked himself the difficult question: “What does the funding provided by the Innovation Fund achieve for innovative structures in standard care?” First of all, Pfaff presented the Innovation Fund as the “third building block” in the promotion of the Health care research - based on basic research supported by the DFG and application-oriented basic research supported by the BMBF. Although the innovation fund largely focuses on application-oriented research into new forms of care (NVF), in Pfaff's opinion, health care research must always be taken into account and seen as a "practical basis for the new forms of care". Pfaff: “If we want to support innovations with research in the future, we need professorships and chairs in the background that have to be set up.” We are currently in the process of doing that, but the efforts need to be intensified, because – says Pfaff – “otherwise it can happen “It could be that we are triggering a huge wave in the NVF, but are too weakly positioned to ride the wave.” It is therefore urgently necessary to establish and expand university health services research at the same time and even more than before. However, a useful side effect is already noticeable: Due to the many applications submitted and approved for the innovation fund, clinicians are suddenly realizing that health services research is apparently “very important”. Now all that is needed is the practical insight that more professorships need to be awarded here, and not just in the biomedical area.
Overall, however, he sees Germany as already on the right path, at least for the first time. In the long term, according to the Cologne professor, we need “R&D in the area of healthcare”; You simply wouldn't be able to get past it. However, this is not research and development, as has long been established in the pharmaceutical or medical technology industry, but rather “R&D for innovation in processes and structures”. In the long run, however, Germany would have to invest much more money in such an innovation structural fund than before; and also more than in the innovation fund previously endowed with 1.2 billion euros from 2017 to 2020 (plus 200 euros per year in the following years).
According to Pfaff, the problem with promoting innovation in and of itself is rather systemic. Niklas Luhmann, the great systems theorist, once postulated that there are technical, organismic (here medical), social and psychological systems. Pfaff: “You have to be aware that a healthcare innovation almost always affects all systems.” But this means that you always have to keep an eye on all systems and the whole thing is an interdisciplinary matter between engineers, doctors, sociologists and business scientists and psychologists. What – and this is often missing in innovation fund applications or integrated pension plans – “always needs to be taken into account”. Because every innovation will and must be implemented into existing technical, medical, social and psychological systems, although every system can defend itself against it. But, which explains high drop-out rates and long implementation times for innovations, people usually think too much in a single system category instead of thinking about all four levels of the system from the outset.
The big problem is that if you want to think about all four systems in order to get a comprehensive overall picture of an innovation, you need four times as much data: biomedical, technical, psychosocial and socioeconomic. Pfaff: “All of this adds up to considerable complexity, which must first be achieved intellectually.” Mind you: in advance!
Once an innovation has been positively evaluated, things continue to be just as complex. “The big challenge with innovations is that you not only have to think about them in advance, but you also have to implement them and integrate them into existing organizations,” said Pfaff, raising the bar a little higher, especially for cross-sector integrated forms of care. And at every step, at every level, something is always lost (Fig. 1.), which is why system theorists differentiate between innovation and built-in innovation, and thus between pure and real effect. It remains unclear how much of the original innovation is actually lost during installation and whether the intended effect can still be achieved.
That's why, and that's why he prefers a translation fund formulated specifically for this purpose, you always have to consider the following: "If a project fails, it can either be due to the innovation itself, or the idea was good but was poorly implemented." Law (SGB V § 92a) has been formulated that the positively evaluated innovation fund projects of the new forms of care must be transferred to standard care. The intended leap into standard care is a point that – according to Pfaff – “has not yet been properly thought through”; including the actual medical necessity, possible alternatives with the same benefit and the question of cost-effectiveness. Pfaff: “If you really apply these three criteria to get into standard care, they are massive hurdles.”
But maybe they are completely normal. At least according to Pfaff, who as chairman of the innovation committee is probably the only one with an overview and says: “In my view, the innovation fund contributes to evidence-based and competition-oriented care development.” Since there is competition in the selection of projects, it has to be done There are also losers - otherwise it wouldn't be competition, but pure subsidy. But one must also allow the innovation fund a certain learning experience, because it is itself “its own social innovation”. <<
by: MVF editor-in-chief Peter Stegmaier