Prof. Dr. At the beginning of the DKVF plenary session, Reinhard Busse (TU Berlin) led “Needs-based design of emergency care” with Prof. Dr. Ferdinand M. Gerlach, Chairman of the Expert Council for the Assessment of Developments in the Health Care System (SVR), an expert interview on the recommendations from the current SVR report on the topic of needs-based design of emergency care. Afterwards - moderated by Busse - the recommendations for integrated control centers (ILS) and integrated emergency centers (INZs) were discussed with Gerlach and representatives of the outpatient sector, the emergency services and the inpatient emergency room.

> When two people with know-how exchange ideas on equal terms in an expert interview, that is an experience and gain of knowledge in and of itself. This is what happened during the technical discussion between Prof. Dr. Reinhard Busse, head of the Health Care Management Department at the Technical University in Berlin, and the Chairman of the Advisory Council, Prof. Dr. Ferdinand M. Gerlach on the occasion of the DKVF plenary session “Needs-based design of emergency care”. If this interesting format is topped, even more so. This made the subsequent panel discussion possible, which brought the knowledge that had just been heard and conveyed - but was actually assumed to be known - about the 2018 Expert Council report on the "needs-based control of health care" from the theoretical to the real care level: proven experts in the outpatient sector (Dr. Dominik Graf von Stillfried from the Central Institute of the Association of Statutory Health Insurance Physicians), the emergency service (Dr. Janosch Dahmen from the Berlin Fire Department) and the inpatient emergency room (Prof. Dr. Rajan Somasundaram from the Charité).
“We have observed how these weightings have shifted in recent years,” said von Stillfried in his opening statement, giving an insight into the development of emergency room numbers in recent years. When the practice fee was abolished in 2012, utilization of both on-call services and in emergency rooms increased significantly. This would have continued with a slight increase until 2015, with a national average decline in cases discharged from emergency rooms from 2016/17 onwards, but an increase in on-call cases of approximately the same magnitude. From the Zi's point of view, this is largely due to the fact that the statutory obligation of KVs to set up portal practices and on-call practices in hospitals, which has existed since 2013, has also been implemented. On-call service reforms would also have taken place in the KVs from 2015, which would explain a slight decline in the number of admissions to on-call service. From Stillfried: “We have just received very current figures from the KVs, from which we can see that the replacement of the emergency room with the medical on-call service is clearly the case at the hospitals where on-call practices have been set up that work closely with the KV According to von Stillfried, the number of a minority of hospitals that do not take part shows that this works, as there has been a significant increase here.

Why is it that so many more people call the emergency services today than three years ago? Busse asked Dr. Janosch Dahmen from the Berlin Fire Department, which has an important dual function in Berlin: On the one hand, she runs the rescue service herself at 70%, and on the other hand, she coordinates and supervises the deployment of all other service providers, mainly those from aid organizations and the Bundeswehr.
According to Dahmen, unlike in other parts of Germany, there is a single control center in Berlin that centrally controls the entire area of emergency rescue. This is a special feature, but it would be due to the supply responsibility of almost four million registered and a very high number of tourists and visitors. However, the increase in the use of the emergency system is not a phenomenon that can be observed in Berlin and Germany, according to Dahmen, “increases that have actually affected all emergency service systems in the Western world in recent years in a similarly dramatic manner”. In his opinion, this has less to do with local phenomena or legislation and more to do with fundamental processes of change in our societies. Dahmen: “We experience, starting from a very auto-
nom organized social structures 100 or 200 years ago, an increasing process of disintegration. In the last few years alone, there has been an increase in single households in Berlin to 50 percent, which would mean nothing other than that every second person in the city lives alone without an immediate social structure in the living area. There is also a very strong increase in older people, who are disproportionately alone, lonely and often poor and represent particularly vulnerable groups in society. “As a result, we see a disproportionate volume of emergency calls wherever network structures are in the process of dissolving in society or are no longer as effective as in the past,” explained Dahmen.
However, other phenomena can also be observed, caused by incentive models and questions of responsibility, which would trigger a shift in areas of responsibility in the area of institutional care. Therefore, he wanted to be able to better cope with the responsibility. “More arrows in the quiver” because it is becoming increasingly clear that the understandable expectations and needs of Berlin cannot be properly served outside of the hospital only with the two forms of service, ambulance and emergency doctor.
In response to Busse's additional question as to who decides which of Berlin's 40 hospitals ("the best?" "the next?") a patient should be taken to, Dahmen replied with a reference to a central matrix created in Berlin, in which not only all clinics are registered, but also in which their respective capacities are held. This is coordinated and regularly updated by the health administration as the supervisory and planning authority for hospital requirements planning together with the Berlin fire department. “As the state of Berlin, we are currently in the process of introducing the web-based interdisciplinary care verification system IVENA eHealth, which is already used in various places nationwide, for the allocation of emergency patients,” Dahmen gave a look into the near future. However, this system is not just a new technical basis, but is also linked to a measure that would significantly tighten the allocation criteria.
“You want more arrows in your quiver,” Gerlach replied to Dahmen’s comments. These would be, for example, the acute care and acute palliative care teams proposed in the SVR report. IVENA also brings an important addition to the triage or initial assessment system. But you have to
eliminate existing false incentives beyond optimization. Almost everywhere in Germany, an ambulance transport (RTW) is only paid for if afterwards
an SGB-V service is provided, which is why many RTW transports end in the clinic. Gerlach: “And once the patients are there, many are admitted to the smaller hospitals.” This chain of disincentives needs to be broken by giving the emergency services their own service provider status, which enables them to carry out treatments on site and, above all, transports must be billed separately as a service, but always with an SGB-V
Link performance. RTW transport could then also be controlled via IVENA to a partner practice and further treatment there.
One of the hospitals that the Berlin fire department travels to disproportionately often is the Berlin Charité. While, as Busse calculated, around 40 patients arrive in an average German hospital in the course of 24 hours, according to Prof. Dr. Rajan Somasundaram, head of the Charité rescue center, has 80 to 90,000 patient contacts per year with the maximum care providers in Berlin, which amounts to around 250 patients per day. But there is no general answer to the question that these patients would be admitted to hospital. “The big centers are not at all interested in admitting every patient,” explained Somasundaram. On the one hand, this is because it is much more attractive for a cardiologist to install an elective valve in a highly complex procedure than to recompense an emergency patient with congestive heart failure. Secondly, which brings us back to economics, the second case is less financial
attractive and may not fit the range of services offered by the respective company.
Which, according to Busse, suggests that certain economic incentives would play a role here. “You don’t have to kid yourself: Yes, of course,” replied Somasundaram, adding that of course the economy plays a role. But it varies greatly depending on the discipline. Pediatrics never admits more than ten percent of its patients as inpatients, while in the field of internal medicine there are sometimes admission rates of 60 to 70 percent. “Some of these patients are seriously ill,” explained Somasundaram. This is also thanks to the high performance of the resident doctors, who have stabilized these patients until there is no other option. Then hospital admission would be urgently indicated. Therefore, Somasundaram's request was: "Let us not blame the patient for coming to us in the emergency room just because he thinks it is an emergency." This is also an expression of a certain pressure, generated by necessity and Uncertainty, although educational elements and control mechanisms are still needed to counteract overuse.
“We need the initial telephone assessment, advice and clarification. But also the control of needs-based utilization,” replied Gerlach. But you can't change the system with just one measure, especially not one with three sectors and its structure that has grown over 100 years. Gerlach: “It is important to me that we have a goal that we can move towards and that we can ask each measure whether we are getting closer to the goal or moving away from it.”
Two of the proposals mentioned in the SVR report are the Integrated Control Centers (ILS) and the Integrated Emergency Centers (INZ). The difference between the two is that where there is an appropriately trained center, adequate care should be provided. But in Stillfried's opinion only when the actual need has been identified. Starting next year, the KBV also wants to offer digital self-assessment, which should not only be online information, but also a kind of emergency app that is available 24/7. “Where I am skeptical is the question of whether we actually have a greater advantage if we organize everything under one roof via the integrated control center,” said von Stillfried. He pointed to the good example of the electronic interface at the Brandenburg control center between the emergency numbers 112 and 116/117 with clearly defined delivery points. The control centers themselves have defined when a case is clearly not an accident after a structured survey and is therefore handed over to 116/117. By Stillfried. “There are good approaches where you can see that digitalization in particular helps, coordination
to get it done better.”
The integrated control centers would also have a similar functional separation, in which the staff who deal with the actual emergency are not the same ones who deal with an acute case. However, the crucial point in both approaches - regardless of whether there is a shared roof over it or not - is that there are always clearly defined handover points.

But 250 control centers for Germany

That is why the draft law also states “joint control centers” and not integrated ones. But that has more to do with the fact that in official jargon, “integrated control centers” mean those between the fire department and the police. He is already satisfied with an initial assessment and integration into the supply level plus technical integration of the control centers. But Gerlach would still think it would be better if the control was handled in one organization, because that would simply be better for shared management, quality development, monitoring and evaluation than if responsibility remained divided into two jurisdictions.
Berlin is already on the right track and in a certain way is unique with the largest control center in the country. But in Hesse, for example, there are two control centers on the KV side and a further 27 on the emergency service side - one in each district - for the around six million residents who live there. “This means we have 250 different rescue control centers nationwide,” calculated Gerlach. He demanded: “We need horizontal integration of the control centers throughout the area.” However, he also knows full well that this will not be easy everywhere. Coincidentally, he knows the control center of the Diepholz district exactly and he doesn't know how “they even want to implement what we are discussing here”. Therefore, there is still a huge task in the regional states. <<

by: MVF editor-in-chief Peter Stegmaier