The health policy spokesman for the CDU/CSU parliamentary group, Jens Spahn, presented 14 proposals for reforming medical care in Germany in December last year. The paper is based on a closed meeting of the CDU's Health Working Group in March 2010 in Gronau, Westphalia, and on a paper by the CSU led by Johannes Singhammer and Max Straubinger. This opened the discussion about the key points of the government coalition for the GKV Care Act (GKV-VG).

>> In January 2011, the Friedrich Ebert Foundation's WISO Discourse series published a study led by Prof. Gerd Glaeske with the title: "Patient orientation in medical care - suggestions for the necessary further development and transformation of our healthcare system."
Both publications therefore assume that
• that medical care needs to be further improved,
• that the range of services offered should be designed based on the needs of the patient
• and suggestions are made from the sectoral perspective of the respective political camp, some of which go in the same and some in different directions.
The CDU paper assumes that it depends heavily on subjective considerations as to what should be considered needs-based in the healthcare system. In this context, it addresses the regional differences in the density of doctors, particularly in the area of primary care.
To solve the problem, a reduction in oversupply and mismanagement as well as the introduction of smaller-scale demand planning are considered. The cooperation between practicing doctors and hospitals should be improved, the structure of the medical care centers should be further developed while strengthening the influence of doctors, the medical profession should be made more attractive by facilitating the cost-effectiveness control of drug prescriptions and by reducing quantity discounts in remuneration. In order to promote young talent, extensive changes to studies and further training are proposed, which, among other things, promise advantages for those doctors who later settle in rural areas.
The influence of general practitioners is to be strengthened in the statutory health insurance associations through an independent right of nomination for the election of a general practitioner board member.
The promotion of competition in the health care system through a separate legal basis for selective contracts, as introduced by the Grand Coalition in the last legislative period, is to be reviewed and is tended to be viewed much more critically by the CDU than was the case at the time of the Grand Coalition.
The approach promised in the title of the 14-point paper of designing the system based on patient needs is reflected in the intention to shorten waiting times for specialist appointments. The health insurance companies and the statutory health insurance associations should ensure this. Hospitals are required to “make the 4-bed rooms still available for those with statutory health insurance in hospitals a thing of the past.”
It should not be denied that many patients would welcome such a development. But are declarations of goals from politicians addressed to service providers already “political design based on patient needs”? These are more likely to be opportunistic promises and positive future scenarios addressed to voters.
In January 2011, the health policy spokesman for the SPD parliamentary group, Prof. Dr. Karl Lauterbach, started an analogous campaign. He wants to fine doctors who make their patients wait an excessively long time for an appointment. He obviously overlooked the fact that such fines have long existed in the professional supervision of doctors by the medical associations, for example when reports are submitted too late or when violations of the professional regulations are punished with fines. The latter is in principle also possible if the waiting times are unsuitable for the job.
Political actions that claim to be based on the patient's needs should first define the patient's needs. And if it is already recognized - and this is the case in the CDU paper - that objectively measurable needs and subjective needs must be carefully distinguished, then one could talk about the political consequences without there being any misunderstandings.
The Glaeske study by the Friedrich Ebert Foundation is based on the author's participation in the expert council assessing developments in the healthcare system between 2003 and 2009. Members of the Advisory Council at this time were: M. Haubitz, A. Kuhlmey, FM Gerlach, M. Schrappe, R. Rosenbrock and E. Wille.
The study selectively contains a variety of analytical material that was prepared by the group of authors mentioned (who are also quoted in the study) on demographic changes, age- and gender-specific expenditure profiles in the statutory health insurance system, the care needs of children and Adolescents and the development of illnesses in this age group, the development of chronic illnesses, age-specific changes and their influence on pharmacotherapy, the supply of medicinal products and aids, etc. The future need for care can be determined by depicting over-, under- and incorrect care can undoubtedly be better determined on the basis of such figures. But has this already achieved the goal of patient orientation in medical care?
Is politics overreaching?
The question arises as to whether politicians aren't actually overreaching themselves when they claim patient orientation? Of course: Politicians can always have a variety of goals in mind when designing health systems. It can improve patients' access to the system and create the basis for continuity, comprehensivity, cost-effectiveness, affordability, quality and transparency of care. It can consider solidarity, the principle of subsidiarity, citizen and patient participation, as well as consumer protection and autonomy. It can strive for evidence-based medicine and promote competition.
But patient orientation has (as the CDU paper correctly states) a strong subjective component and this can hardly be influenced politically. Here, politics can at best create protective spaces for the relationship between those receiving care and nursing staff, patients and doctors, etc., in which these relationships can develop with their subjective part. However, for the quality of care and for its effectiveness and cost-effectiveness, the possibility of developing this subjective component in a care relationship is just as important as the objective aspects of evidence-based medicine.
This also applies to competition, which always has subjective components that are not sufficiently expressed in the political papers, regardless of which political camp they come from.
The most important level of competition in the healthcare system takes place within health insurance companies between healthy and sick insured people, the so-called patients themselves. Around 80 % of the expenses in the GKV are incurred for 20 % of the insured persons with patient status. However, healthy insured people behave differently than sick people. If the additional contribution is higher, they change health insurance companies, as the DAK experienced in 2010 when it lost over half a million insured people. In general, the following applies: Sick insured people want optimal care, while healthy insured people want the lowest possible premium.
There are interests not only among the service providers, but also on the part of the insured. A policy that claims to be patient-oriented must deal with the majority of those insured by statutory health insurance and thus the voters and clarify the question of how much money from healthy insured people can be spent on improving care for the sick and thus on patient orientation .
In this context, one should remember the statement by Herder-Dorneich (Phillip Herder-Dorneich: “Cost expansion and its control in the health care system”, Deutscher Ärzteverlag Cologne, 1976), who stated as early as 1976 that patients and doctors alike find themselves in a “ “Rationality trap”. Patients who pay high health insurance contributions are behaving unreasonably in terms of their personal economy if they do not take advantage of this service. But if they behave sensibly in their own interests and take advantage of everything the system offers, then they are damaging the collective. By pursuing their own claims rationally and legitimately, they make non-legitimate or even non-legal claims from the perspective of society and thereby violate collective interests and moral claims.
The economic goal of society is to purchase as many health services as possible from so-called service providers with as little money as possible. The personal economy of the doctor, on the other hand, consists in increasing his sales, because this is one of the prerequisites not only for optimal business results, but also for medical results in a practice. He can then either increase profits while keeping costs constant or make better use of equipment despite rising costs and thus maximize profits.
What is needed for the next and probably subsequent health care reforms is a resource-saving control system that not only has an eye on the profits of industrial service providers and the pharmaceutical industry. A lot is already happening there. However, the competition between healthy insured people who are obliged to pay, sick people in need of care, and between power-conscious politicians who promise the people benefits that all taxpayers and contributors in society then have to work for, has so far hardly been controlled. This is where both health services research and political discussion should start. <<
by: Professor Dr. med. Klaus Dieter Kossow