New law raises concerns for Germany’s out-patients
Under a new health delivery Act only seriously ill in-patients will receive out-patient treatment at the same hospital. The rest will have to go to a new ‘medical specialist service’. The new system can only cause problems say medical workers. Report: Susanne Werner.
Germany´s VStG (Healthcare Delivery Structure Act) will revise the delivery of out-patient specialist medical care at the interface between out- and inpatient sectors. The new law stipulates that only seriously ill in-patients can continue out-patient care at the same hospital – a reform criticised by the country’s hospital staff. ‘The new provisions ought not to so limit the clinics that, after hospitalisation, patients may no longer take advantage of the hospital physician with whom they are familiar and have placed their trust,’ warned Dr Josef Düllings, President of the VKD (Association of Hospital Directors in Germany).
With the VDGH (Association of the Diagnostics), in March the VKD hosted a management seminar in Berlin entitled The Future of Patient Care Delivery – Legal Challenges and Hospital Best Practice), focusing on the revised §116b Social Security Code (SGB) V, which stipulates that previously supplied out-patient treatments at hospitals will be transformed into the ‘out-patient medical specialist service’ (ASV).
Applications for ASV work
Clinics and contract physicians wanting ASV work must apply to their respective state agency and, if no refusal is issued within two months, their work may commence. Expertise must be demonstrated beyond that of a general specialist physician’s qualifications. In addition, high standards of facility organisation, technology, architecture and hygiene must be met. The hospital physicians and medical specialists in private practice are to be reimbursed by health insurers for this new service at the same rate, i.e. as an individual service at fixed prices without budget controls. The view is ‘Whoever can, will be allowed’. The rather non-bureaucratic access to the ASV aggravates health insurers.
At the Berlin meeting Johann-Magnus von Stackelberg, chair of the GKV (umbrella association of the state health insurers’ associations) demanded ‘…a coherent public policy solution that prevents unnecessary general increase in services’. Currently the legal provisions are so unclear that many interpretations are conceivable. Indeed, there is still much needed clarification. The G-BA (Joint Federal Commission) has to issue appropriate directives for specific implementation by the end of 2012. The law provides that, in the first instance seriously-ill patients or whose illness has been particularly difficult, as well as those with rare illnesses and those needing highly specialised services, are to be taken up by the new delivery service and provided with hospital out-patient treatment.
Presumably the majority will be cancer patients. While the illness is comparatively easy to define, dealing with other requirements is more difficult: Is there such a thing as a mild form of cancer? If so, how can it be defined? Is it possible to estimate the scope of treatment for the various illnesses in advance?
Potential healthcare delivery gaps
German hospital directors expect that ultimately their institutions will be disadvantaged. While the hospitals will have to maintain many services, patient access to them will be restricted significantly and also will raise questions regarding remuneration. Above all, representatives of highly specialised facilities, such as the Comprehensive Cancer Centre, view the legislation sceptically. Others fear that the new law will threaten the overall provision of medical care. Thomas Kruse, department head at the Kiel Municipal Hospital warned: ‘In future, hospital out-patient services will have to limit themselves to a certain spectrum of illnesses. This can lead to gaps in healthcare delivery, especially in rural areas’
His feelings are also mixed over the cooperation between hospitals and contract physicians mandated by the law. In his experience such cooperation is difficult to establish because the relationship involves an unequal burden: ‘Clinics have to consider the interests of the private specialist practitioners because they can channel the stream of patients by changing their referral practice and also hinder the hospitals’ market entry.’ Dr Düllings sees the new provision as ‘tightening the thumbscrews’ on the hospitals. Ultimately, he believes, the out-patient sector is not even prepared for the specialist medical care delivery. ‘Patients already experience long waiting periods for out-patient physician appointments. For that reason alone, the options for pre- and post-hospitalisation urgently need expansion.’
21.05.2012
