Healthcare money will last long after waste stops (Part 1)

You can hear everywhere that the German healthcare system can no longer be financed and that billions are once again threatened. Since, understandably, expenses cannot increase arbitrarily, savings must be made. The only question that concerns everyone is whether rationing, i.e. a targeted undersupply in certain areas (e.g. no measures after a certain age), needs to be prescribed, or whether the system is simply too wasteful with the resources, which are really not small. and limiting waste can help postpone impending rationing. This overview shows the background to the high costs of the German healthcare system, its relative inefficiency and possible savings potential, thereby providing arguments that we could still be a long way from rationing if the savings potential could be exploited.

>> When statins were introduced around 15 to 20 years ago, lack of knowledge was the most common reason for not taking an ethically motivated and necessary fat reduction therapy. Over the course of the following 10 years, the findings became very widespread, but despite this there was hardly any improvement in this area because the doctors' hands seemed to be tied by the at least threatened recourse and this led to the drastic undersupply, even according to the latest data comes to this area.
“Concealed” rationing in Germany:
Limitations on medical care
are everyday life in Germany in 2009
In Germany, 8 years after the results of the Target Tangible study (5 % patients properly cared for in secondary prevention, März et al. 1999), only about 12 % patients with dyslipidemias in the NCEP III class have been correctly diagnosed and treated [Böhler et al. 2007].
The same applies to the treatment of high blood pressure. In the largest primary medical epidemiological study ever carried out in Germany (55,000 patients with all cross-sectional characteristics that one can imagine: geographical, urban/rural, east-west), around 70 % hypertensives were diagnosed, especially among the older patients, slightly more than 65 % hypertensives were diagnosed and treated, but only between 22 and 25 % were controlled, ie in the range of the desired target values [Pittrow et al. 2007, recommended web page http://www.detect-studie.de/].
Budgeting is certainly not solely to blame for this undersupply; There is also no reliable data on the extent to which budgeting is the cause here in percentage terms. However, from my numerous conversations with practicing physicians, it is clear that they are involved in a significant portion of the undercare problem in areas where the symptoms are not the cause and require therapy.
There is clear scientific evidence that there is much better control of blood pressure, for example, in other countries with significantly lower health expenditure [Boersma et al. 2003]. Here, compared to other industrialized countries, the prevalence of hypertension was highest in Germany, with well over 50 % among the working population.
Given the lack of options for demarcation, the budget limitation must clearly also be seen as the cause in view of this dramatic misery in preventive medical care in Germany. In the Netherlands, doctors are paid based on how well their patients are adjusted. So he is not punished for well-adjusted patients through budget regulations/recourse, but is even compensated in pecuniary terms. Apparently people are starting to talk about such reward models in Germany too.
A shortage of doctors generally occurs when a doctor only has 5 minutes for a patient. It is obvious that this is a purely structural problem given the still very high density of doctors in Germany: in order to achieve sufficient sales, doctors themselves also have to tolerate unnecessary visits. There is no filter system like in Scandinavia, where the doctor is only seen by the patient after pre-sorting by nurses. So there is a “homemade doctor shortage”, but this reflects economic restrictions rather than a real doctor shortage. However, 5-minute medicine does not allow further engagement with the patient and thus the application of “thinking medicine”. This leads to pointless overtreatment, polypharmacy and an estimated 20,000 drug-related deaths every year in Germany alone. This number is an estimate that lies between 6-8,000 determined by Schönhöfer and 60,000 estimated by Fröhlich [Schnurrer, Fröhlich 2003; Schönhöfer 1999]. Based on experiences from the USA and other countries, it probably corresponds more closely to reality, although the lack of pharmacoepidemiology in Germany makes such estimates very uncertain.
In addition to this unreal shortage of doctors, there appears to be a real shortage of doctors in individual areas, especially in the north-east of the Republic.
The shortage of nursing staff is certainly already real, especially in the area of geriatric care [Fig. 1, The Dementia Carers' Survey and Report, 2006].
The nursing shortage that already exists, particularly in the elderly sector, will only increase due to the aging of the population, but also the aging of the workforce, as the corresponding figures from Switzerland show [Ruedin and Weaver, 2009]. In addition to today's nursing shortage, there will be a shortage of nursing staff: between 120,000 and 190,000 additional people will be needed in Switzerland by 2030.
There are no fundamental differences in these areas between the countries mentioned and Germany. The further rationing arises from the fact that doctors in private practice, but also hospitals, have recently been given certain case numbers and, once these case numbers have been processed, can no longer treat patients in these areas without having to pay for it out of their own pocket. It is unclear to what extent this is already having an impact on undercare, as there is oversupply in many areas from which doctors are now complaining (e.g. orthopedics). This certainly needs to be followed closely. In general, the care in acute medicine in Germany can still be described as very good. We have much bigger problems in the area of preventive medicine than other countries, for example Sweden or the Netherlands. We don't have any significant waiting times for important operations, such as those in Sweden. From there, numerous orthopedic patients are sent to Germany so that the operations can be carried out on time. A distinction must be made here between undersupply, especially in the area of transplant surgery, due to a lack of donors, which is not caused by budgeting or rationing on the part of the healthcare system.
Patient demands as a cost driver?
Patients who are suffering always demand therapy, even if it does not exist. Therefore, doctors are often forced by patients to write down nonsensical therapeutic agents. This will often also happen in the area of ineffective medications, which also incur costs. Patients are often unable to be convinced of non-therapy or alternative therapy, e.g. with lifestyle changes instead of medication. Also in the area of carrying out diagnostic invasive or therapeutically invasive procedures, such as: B. with cardiac catheterization, patient expectations often play a role. Particularly in the area of imaging, there is demonstratively controlled behavior on the part of patients, for example in that the patient can see “narrow spots” in the coronary vessels in the images and he also pushes for the vessel to be enlarged despite better medical advice. However, the opposite case is more common, as the cardiologist can earn good money from this. This should be distinguished from patients whose efforts to be ill cause unnecessary costs in order to realize a so-called secondary or tertiary gain from illness, ie to escape from an unloved job or even to strive for early retirement. Here, too, it is very difficult for doctors to ward off such requests. Overall, I think this problem is currently declining in quantitative terms, as work itself is seen extremely positively as an increasingly rare commodity and the escape into non-work seems to be rather unattractive.
A related problem, which causes a turnover of around 4 billion euros per year in Germany, is the senseless spa system. This is also something that is largely demanded by patients based on their own or others' previous experiences, but is also readily supported by the providers who make a living from it. Even if rehabilitation medicine has a clear importance in the area of surgical aftercare, the pure treatment, in which prevention concepts are often used, has been proven to be completely ineffective in terms of its long-term effect. In other words, even if blood pressure, blood sugar and other parameters are well controlled during the treatment, there is research that shows that these effects are extremely fleeting after returning to everyday life and in no way induce the necessary lifelong lifestyle changes necessary for a lasting effect were. With the exception of the size of the spa industry, however, it is difficult to provide figures for these assumptions, which are certainly part of the savings potential.
The most important cost drivers are financial incentives,
to provide unnecessary medical services
The incentives to initiate medically necessary examinations and therapies come from two sources:
1. Financial incentives
2. Forensic aspects
Since the examinations carried out under 2 have a fundamentally different motivation than a medical one, which is not in question, they will not be discussed further here.
The main cause of waste in the medical field is misplaced financial incentives. The basic mechanism is always the same: investments are made that are intended to pay for themselves for purely economic reasons and also generate the largest possible profits. This applies in an exemplary manner to the large medical technology devices in the field of radiology (which also includes cardiac catheters) as well as to the entire operating room complex (here is the entire apparatus that is built around an operating room with all the specific sub-devices such as anesthesia machines and surgical machines and other equivalents to a “device”).
Germany is a numerical leader in a few medical disciplines. However, in the density and frequency of cardiac catheterizations and interventions such as PTCA, this is clearly the truth. According to the 2005 heart report, 9,366 left heart catheter examinations were carried out per million German citizens, in Austria only 5,537 and in Switzerland only 4,885. For the PTCA the numbers in Germany were 3,287, Switzerland 2,229 and in Austria 2,072 [Bruckenberger 2006]. In an even more extensive international comparison [Dissmann, Ridder 2002], Sweden was around 30 % below Switzerland in this regard, i.e. around a third of the studies in Germany.
There are around 35 left heart catheterization places in Munich. According to our own estimate, this corresponds roughly to the number of left heart catheterization places in Sweden (10 million inhabitants), although only 2 million inhabitants in Munich have to be cared for. The resulting massive oversupply (which is not so drastic across the board even in Germany) has been reflected in a quip that is often told in the Munich area: “What is the most dangerous thing about the traffic jam on the motorway near Munich? That you accidentally get a cardiac catheter..."
Nevertheless, the Germans are no longer living. In terms of their overall life expectancy, they are in the middle (78.8 years), far behind Sweden (80 years) and Switzerland (80.5) [Statista 2009]. The Germans are also not favored when it comes to the number of deaths from cardiovascular diseases: they lead the statistics compared to Finland, Great Britain, Sweden, Italy and France [Fig. 2, OECD 2006].
Germany spends the most on health (after Switzerland and the USA) [Fig. 3, OECD 2006].
In addition, Germany has the highest density of specialists (Fig. 4), but the highest prevalence of hypertension in Europe and North America (see above).
The so-called COURAGE study [Boden et al. 2007] showed that an invasive strategy with a cardiac catheter is in no way superior to good medical therapy. It is therefore not surprising that, despite an oversupply of cardiac catheters, the highest density of specialists, and the highest healthcare costs, life expectancy and, above all, cardiac life expectancy in Germany is mediocre to poor compared to other countries.
Invasive cardiology is by no means a solitary cost driver
In the following table [Table 1, HSTAT 2008] you can see that in many studies, mainly from North America, the proportion of unnecessary or uncertainly indicated coronary angiographies or PTCAs is now very high, and in some cases even the majority of cases were not indicated (Table . 1).
Due to the even higher density of catheters in Germany, it can be assumed that these numbers are much worse here.
This list also contains other measures that need to be discussed in connection with the question of overtreatment and that are massively overused.
An example of the “large-scale device” operating room is carotid endarterectomy, which is sometimes carried out just as often when it is not indicated as when it is indicated.
A much smaller problem in terms of numbers or magnitude arises from the advertising/promotion of unjustifiably expensive new drugs by the pharmaceutical industry, which in any case exists. Here, new medications are often pushed onto the market that do not represent any real progress (so-called “me-too” preparations), but which do not provide any significant or very small incremental advantage over older preparations. The fact that doctors' prescribing behavior is influenced by bribery-like measures is well known and is certainly a grievance. In numerical terms, these sales play a subordinate role compared to the sales generated from unnecessary diagnostic measures and operations. According to our own estimates, a maximum of 3-5 billion euros is wasted in the pharmaceutical sector, but in the other areas mentioned together, it is easily 10 times as much wasted. <<