How do hospitals waste money?

Hospitals between medicine and economy: The search for the right balance

In the past, the reimbursement of hospital services was an invitation to waste. In the meantime, the pendulum is swinging too far in the opposite direction: the need to save is getting out of hand. It is important to find a reasonable balance between medicine and economy in the hospital.

There is the elderly patient who has come to the clinic to undergo an outpatient colonoscopy. She has to wait a long time for her examination. When it finally starts, the old woman soon complains of severe pain and asks that the procedure be terminated. But the doctor ignores the patient's request. He wants to do the colonoscopy quickly as planned, and finally more patients are waiting outside. The patient should then go home as planned despite the continued severe pain. Only her committed daughter succeeds in preventing this. Later it turns out that the intestine was severely perforated during the mirroring. Emergency surgery and a long hospital stay followed.

No time for attention

Another example: a self-confident woman around 40 is undergoing hip surgery. A few days later, she complained of pain, but nobody in the hospital takes it seriously. When the woman wants to take a shower, she is told to do it herself. One is understaffed, no nurse has time to help her. The weakened patient collapses in the bathroom. The surgical suture had inflamed badly under the bandage. This is followed by several operations and a long rehabilitation until the woman is healthy and able to work again.

Both examples come from Carola Sraier's day-to-day consulting work: “The impression that a patient is not taken seriously with their complaints in a clinic, that they feel alone and helpless is increasing,” reported the spokeswoman for the Federal Working Group of Patient Agencies in Dresden at the end of October . The German Ethics Council invited to the public conference “From the hospital to the sick house?” In the German Hygiene Museum. Elderly and single people in particular expressed increased fears and worries that they would have to stay in hospital again, according to Sraier. Many patients' trust in the hospital as an institution was severely damaged by their experiences.

"We doctors are forced under the current conditions to withhold a very important resource in the doctor-patient relationship from our patients - and that is the time," confirmed Prof. Dr. med. Arved Weimann, chief physician at the clinic for general and visceral surgery at the St. Georg Clinic in Leipzig. The same applies to the nursing staff. "At the expense of an empathetic doctor-patient relationship, the patient threatens to become a workpiece in an industrial process," says the surgeon.

Wrong incentives

But not only that the daily clinical routine leaves hardly any time for attention to the patient and this leads to undersupply. Worse still: There is suspicion in the room that more operations than necessary are being performed in the clinics. Monetary incentives motivated the doctors to charge more and higher flat rates per case.

Evidence that such an economically motivated oversupply is a reality in German hospitals was recently provided by the study “Dealing with shortage of funds in hospitals” by the Department of Medical Management at the University of Duisburg-Essen by Prof. Dr. med. rer. pole. Jürgen Wasem. 39 percent of the 1,432 chief physicians participating in the study stated that the economic framework conditions in their specialty led to excessive numbers of interventions. In cardiology it was as much as 61 percent, and for orthopedists and trauma surgeons just under 50 percent. Seventy percent of chief physicians were of the general opinion that the shortage of funds in hospitals is having a negative impact on patient care.

"How do you feel as a doctor when you subject a patient to an operation that involves risks without actually having to?" med. Christiane Woopen, the chairwoman of the German Ethics Council, in Dresden. It is clear that the doctor always has a certain amount of leeway when deciding whether or not to have an operation. In this context, chief physician Weimann spoke of the doctor's “indication corridor”. His example: an 82-year-old patient with an asymptomatic inguinal hernia and moderate comorbidity, sent to the hospital for an operation by the family doctor. The doctor could represent an indication for an operation, but he could also wait first, explained Weiman. His observation: "For economic reasons, there is an increased willingness in the operational subjects to exhaust such corridors of indication in favor of an increase in quantity."

Doctors and nurses have to make decisions in hospitals every day, in which they have to weigh medical and economic arguments. This causes emotional stress, as an example from Switzerland shows, where since 2012, diagnosis-related flat rates (Diagnosis Related Groups = DRG) have been billed: A woman, 72 years old, has an emergency hip operation after a fall and is supposed to be postoperatively for prophylaxis be mobilized from bed two to three times a day from pressure sores and pneumonia. Because she is very insecure and prone to dizziness, one person is not enough for mobilization. The patient is moved less and less, and when she asks the nurse about it, she says: “I have absolutely no time for you at the moment. Simply no time. ”For herself, the nurse thinks:“ What kind of person are you that you now just let a patient lie in bed. That is just not ethically justifiable. If the woman gets pneumonia now because I left her ... But there was no other way. I go home so dissatisfied and think, I've never been like that ... "The example comes from the position paper" Medicine and Economics - What Next? "Of the Swiss Academy of Medical Sciences. A conclusion: “Doctors and nurses experience in their everyday life that they can act either in the interests of economic interests - of their employer or their own - or in the interests of the patient. This brings you into a conflict of interest. "

The more the economy abandons its function as an enabling condition for medicine and mutates increasingly into a control instance not only of processes but also of priorities in medicine, the more medicine loses its social character, stressed the Freiburg medical ethicist Prof. Dr. med. Giovanni Maio at the Ethics Council meeting. Medicine is increasingly withdrawing to formalistic correctness and only offers procedures that are also profitable. Maio: "The patients are then no longer perceived as suffering people, but are redefined as consumers who are there to take advantage of their illness to generate good numbers." Such a gradual revaluation of medicine can neither in the The sense of the sick should still be in the sense of the healing professions: "The doctors and nurses feel guilty every day."

Creeping economization

But how did it come to this? When did the social institution hospital become the commercial enterprise hospital? It is probably not enough to attribute the current problems of hospital care in Germany to the introduction of the DRG system a good ten years ago. Rather, an increasing influence of market-oriented health economists on the hospital policy of the changing federal governments has been observed since the 1980s, as the political scientist Prof. Dr. phil. Michael Simon from the Hanover University of Applied Sciences carried out. Simon quoted from a policy document of the Federal Ministry of Labor from 1989, which at that time was still responsible for health policy. For the first time, keywords such as “step-by-step further development towards a price system”, “internal budgeting”, “internal economic incentives”, “involvement of chief physicians in budget responsibility” or “success-dependent chief physician contracts” were used. This turning away from the postulate of services of general interest as the highest principle of hospital policy has remained true to this day. Simon: "The result is a creeping economization of working conditions as well as an advance of economic ways of thinking and calculations in areas that were previously not shaped by economic orientations."

Enormous cost pressure

Undoubtedly, the orientation towards economic goals in the hospitals has once again increased significantly with the changeover of the financing from daily rates to diagnosis-oriented flat rates from 2004 onwards. Since then, the treatment of a patient has been more complex than covered by the flat-rate remuneration, and the hospital makes a loss. If you succeed in working more economically than calculated when calculating the DRG flat rate, you can make a profit. It is crucial that the patient does not stay too long or too short in the clinic (graphic).

A consciously or unconsciously constructed mechanism in the German DRG system ensures that the cost pressure tends to increase: First of all, fixing the prices on the basis of the average costs of the calculation hospitals forces all clinics whose costs are above this average to reduce their costs. If this succeeds, this will again lead to a reduction in the average cost in the next round of calculations and consequently also in the price to be newly determined on this basis. However, as a result of this lowering of the price, clinics are again under cost pressure and have to reduce their costs. Ultimately, this calculation logic leads to a downward spiral in prices. “As a hospital, I ensure that the prices I receive for a service deteriorate every year,” said the psychologist and psychotherapist Michael Wunder, member of the German Ethics Council, commenting on this effect.

But only in connection with the declining and meanwhile insufficient investment subsidies by the federal states and the fact that the price increases granted for hospital services have been lower than the wage increases for employees for years has the DRG system triggered cost pressure in the hospitals that today is hardly justifiable. The economic situation of many hospitals is extremely tense, around half of the hospitals are in the red.

What to do? In any case, medical ethicist Maio in Dresden stressed that going back to the old financing system using daily rates could not be a solution - because that had actually invited people to waste. However, it is ethically necessary to use the resources that are always scarce in the best possible way.

Politicians have a duty

One thing is clear: after years of waste in the old system of daily rates, the conversion of the billing system to the DRGs initially triggered overdue restructuring in the clinics. All processes were questioned and optimized. As a result, many services are now performed more cost-effectively than before. The money saved in this way can be used more sensibly elsewhere in the system. But now the compensation strategies of the hospitals are as good as exhausted and the pendulum is swinging too much in the other direction: the need to save is getting out of hand. The task now is to find a reasonable balance between medicine and economics in the hospital.

Politicians have a duty to help hospitals, their employees and their patients. First and foremost, it is about reducing the economic pressure in the hospitals. The federal-state working group, which wants to present proposals for hospital reform by the end of the year, is particularly required to work out a solution for the investment costs. Because if hospitals have to finance investments from the DRG proceeds, this money is missing for the care. In order to take harmful competitive pressure out of the system, politicians should also have the courage to make unpopular decisions and to close departments or hospitals where there is oversupply. To do this, politics in the current system misuses the economy. Necessary clinics in the area with few and simple cases could, in return, finance the holding costs in order to secure their existence. It must also be allowed to ask why 100 percent financing of all clinic services is based on flat rates per case. Other countries that use DRGs only use them as one instrument among others for agreeing hospital-specific budgets.

"Little by little, a way of thinking creeps in that threatens to turn medical logic upside down," warned Maio in Dresden. This reorientation of thinking takes place almost imperceptibly in the consciousness of the health professions. Prof. Dr. med. Dr. phil. Dr. theol. Eckhard Nagel, Medical Director of the University Hospital Essen and member of the German Ethics Council, added: "The more medicine learns to think in terms of profitability, the more it will first and foremost say goodbye to the weakest."

Jens Flintrop