Government commission recommends dismantling dual specialist medical pathways

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Written By Kampretz Bianca

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Federal Minister of Health Karl Lauterbach (SPD) in the endoscopy department during a visit to the Sana Clinic. There he was presented with the report of the government commission. /image alliance, AFP POOL, John Macdougall

Berlin – The government commission for modern, needs-based hospital care today presented a series of recommendations with which, in particular, sectoral boundaries between the inpatient and outpatient sectors should be overcome.

In addition to joint planning for both areas, this includes, among other things, the development of level 1i hospitals – in the hospital reform law these are called intersectoral care units – the development of a primary care system and the introduction of regional budgets.

The commission’s tenth statement, entitled “Overcoming the sectoral boundaries of the German healthcare system”, was delivered today by its head, Tom Bschor, to Federal Health Minister Karl Lauterbach (SPD) in Berlin.

“Sectoral separations – in particular the separation of the outpatient-inpatient sector – create significant mismanagement and other problems, some of which were identified decades ago,” says the statement.

“Sector boundaries are deeply embedded in the healthcare system and are one of the main reasons for inefficiency.” For reform approaches, the most relevant treatments are those that can be provided on an outpatient basis, rather than full-time, part-time or day inpatient care, and are therefore in principle open to service providers in the two (previous) sectors.

“If we don’t break down sector boundaries, we won’t be able to provide the baby boomer generation with the number of skilled workers we now have in the healthcare system,” Lauterbach emphasized.

“For the 1,720 hospitals in Germany, we do not have enough doctors and nurses, nor economic conditions or medical needs. Today’s structures are in no way sustainable. We need to use medical staff more efficiently.”

Urgent need for reform

“The need for reform has become so urgent that we can no longer avoid a general overhaul of the German healthcare system,” Bschor emphasized. The main reason for this is the shortage of qualified workers. “This year, 1.4 million people celebrate their 60th birthday,” said Bschor – but only 800,000 people celebrate their 20th birthday.

“If we really want to overcome sectoral separation, we have to plan the outpatient and inpatient areas together,” continued Bschor. “This means we can start with level 1i hospitals, which can be planned regionally.”

You might then see, for example, that there is good coverage of practicing cardiologists in a region, but perhaps there is not good coverage of urologists. The specialty of urology could then be increasingly represented in hospitals.

In this context, Lauterbach emphasized that politicians do not want to attack resident experts in any way. It’s just about creating the possibility for resident specialists to work in hospitals in regions where there are not enough specialists to guarantee hospital and outpatient care. “We are currently analyzing whether it is possible to introduce a hybrid doctor who can work both in the hospital and as a contract doctor,” said the minister.

Quality specifications for level 1i clinics

In its report, the government commission makes recommendations that can be implemented in the short term and recommendations for long-term implementation. In the short term, Level 1i hospitals, which the commission had already described in its third report, could be built.

These hospitals must therefore be able to provide both outpatient and inpatient services in order to ensure regionally flexible and integrated healthcare.

In order to prevent level 1i hospitals from carrying out complex treatments, the Commission proposes that autonomous partners draw up a positive list of treatments that a level 1i hospital is authorized to carry out.

“To ensure quality of care, staffing and other structural quality specifications for level 1i hospitals should be developed by autonomous partners, for example in the Federal Joint Committee,” the statement continues.

Institute outpatient clinics and affiliated doctors

Furthermore, the commission describes in detail how it envisages the future creation of level 1i hospitals. These should mainly offer outpatient treatment, bill based on fixed daily rates and be planned by the federal states. If there is a shortage of care in a region, they must charge the legal health insurance associations (KVen) for outpatient services.

They should negotiate budgets with KVs in order to regulate compensation for outpatient services for treatments that were previously provided as inpatients, even in areas that are not underserved. Level 1i hospital locations must also provide space for other health services, such as pharmacies, doctors’ offices, health care centers, health kiosks, medical supply stores, or other health professions.

Measures to be implemented in the short term also include the creation of the institute’s outpatient clinics, the development of the hybrid DRG and the expansion of the system of affiliated doctors. The committee recommends expanding the possibility of establishing outpatient clinics based on the model of psychiatric institute outpatient clinics to other disciplines, as these offer a proven opportunity for intersectoral care and now make a relevant contribution to outpatient care in the disciplines of psychiatry and children. and adolescent psychiatry.

“To overcome sectoral boundaries in both directions, the system of accredited doctors, which has become increasingly less important in recent years, needs to be strengthened, that is, with the participation of the Federal Association of Accredited Doctors and Accredited Hospitals and others competent entities associations and institutions, obstacles must be identified and then reduced and incentives created”, says the statement.

Dismantle the “specialized double track”.

Medium- and long-term measures include the establishment of regional committees under the state presidency that jointly plan outpatient and inpatient care, and the establishment of a system of primary physicians comprised of general practitioners, internists, pediatricians, gynecologists, and psychiatrists who control health care. and the “specialized dual carriageway” “should be dismantled”.

In the medium and long term, comprehensive care by qualified nursing staff with extensive skills should also be implemented – including a restriction on medical consultation – and regional budgets should be introduced.

“Joint planning of outpatient and inpatient care by a regional planning committee makes sense for all regions and hospitals at all levels, since the true overcoming of sectoral boundaries is linked to harmonized and intersectoral planning”, states the communicated.

As a future model, the government commission recommends, in a similar way to the broader state committees, the creation of committees with equal representation that plan outpatient and hospital care in a state or federal region in all sectors.

Finally, the Commission states that there are already numerous special regulations in Book V of the Social Security Code that are intended to soften the sector’s boundaries. “What they essentially have in common is that they did not lead to a fundamental overcoming of the sector’s problem”, stated the commission.

Furthermore, the practical implementation of most regulations is hampered by legal, bureaucratic and organizational obstacles. “In the medium term, we want to stop having special regulations to overcome the sector’s borders,” said Bschor.

Lauterbach explained that BMG would examine “whether we should incorporate the government commission’s recommendations into hospital reform or health law in the near term.” The minister’s expectation is that the hospital reform will be placed on the cabinet’s agenda on May 15th.

BMG is currently in close coordination with the Federal Minister of Justice on hospital reform. “We want to be absolutely sure that the law does not require approval in the Federal Council,” said Lauterbach. That’s why it’s being closely scrutinized. He made it clear once again that he did not want an opening clause in the reform that would allow states to bypass uniform quality requirements across the country. © fos/

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