07/10/2012

Surgeons ‘fire a warning shot’ over Germany’s hospitals

Are surgeons still opting for surgical procedures solely for medical need – or are economics forcing their decisions?
That vexatious question, posed at the 129th Congress of the German, was spurned at the outset by Markus W Büchler MD, President of the Society and Medical Director of the Department of General, Visceral and Transplant Surgery at University Hospital Heidelberg. ‘We surgeons must campaign for surgery that is purely orientated around the patient and his illness.’

Focusing solely on the patient’s well-being is a noble objective when many hospitals are struggling for survival, EH correspondent Susanne Werner reflects: ‘In the battle to attract patients, hospital managers are involving consultants by offering them lucrative contracts’.

For many years German hospitals attracted considerable criticism, with experts deeming their numbers to many and lengths of stay too long. Reforms were meant to alleviate the problems and so, in 2003, the Diagnosis Related Groups (DRG) System was introduced, essentially altering the way hospitals are reimbursed for their services into a flat rate per case system.

Meanwhile, a fifth of hospitals have closed over the last 20 years, with the loss of 150,000 beds. Additionally, the average length of patient stay has decreased from 14 days (1991) to 7.9 days (2010). Nonetheless, the hospital market is far from recovered: ‘Around every fourth hospital in Germany is in debt,’ Professor Joachim Jähne MD pointed out. ‘The investment backlog is around €30 billion.’ As Head of the Clinic for General and Visceral Surgery at the Diakoniekrankenhaus Henriettenstiftung in Hannover, and the third DGCH Vice President as well as the hospital’s expert on the debate around economic pressures and viability.

From daily experience he knows that German hospitals must constantly negotiate the balance between economic necessities and responsible, ethical patient care. However, many establishments struggle with this balancing act. ‘In order to work efficiently from an economic point of view many hospitals feel impelled to increase their patient numbers,’ he says, referring to the statistics. According to federal healthcare reports, 1.2 million more Germans receive hospital treatment now than ten years ago. ‘It is questionable whether this increase in case numbers is in fact always based on justifiable medical indications or whether decisions are actually made for financial reasons due to the enormous financial pressure on hospitals,’ he reasons. 40-50% employment contracts contain bonus clauses DGCH presidents Professors Büchler and Jähne are particularly adamant that surgical consultants must not let themselves become involved in economic purposes and objectives. This means they should have the integrity to object to operations that they do not consider medically necessary but are being scheduled due to economic pressure.

However, adhering to this ideal is unlikely to be always easy. After all, according to Prof. Jähne, around 45-50% of employment contracts now contain bonus clauses, the objective of which is an increase in case numbers. Prof. Büchler: ‘When hospital beds must be filled and the performanceoriented contract of a consultant and head of department impacts on hospital income then there will be individual cases where a bed on a surgical ward will be occupied by a patient who possibly might not really need the surgery.’

This, he adds, puts a strain on the doctor-patient relationship and causes conflicts with the objective ‘Surgery in Partnership’, the slogan for DGCH meeting, where bonus regulations linked to increasing case numbers were widely discussed. ‘The DGCH recommends that these types of contracts should not be entered into,’ Prof. Büchler stresses. ’Surgeons will remain credible if they diagnose an indication for surgery based purely around the likely benefit to the patient and if they resist those wrong incentives enter the healthcare system.’ He also criticises the German Hospital Association, which provides a respective clause in its standard contracts. ‘We object to these standard contracts. The responsibility for economic risks must not be shifted onto the consultants. We would prefer that employment contracts contain other objectives, such as the introduction of risk management systems.’

Next to the increasing patient numbers, hospitals sometimes also try to make more profit through their choice of surgical technology. ‘Patients are then operated on using the very latest procedures, which, although not always more effective than conventional solutions, are often a lot more lucrative from a financial point of view,’ he explains, giving examples such as unnecessary procedures for hernias or arthroscopies. However, despite all austerity mandates and ethical appeals Prof. Jähne is certain that healthcare in Germany, along with Switzerland, is in the lead Europe. Nonetheless, doctors and their professional associations must still face up to the serious balancing act between economic efficiency and patient benefit. ‘The debate at our congress was intended to encourage this. We wanted to fire off a warning shot and emphasise that the German healthcare system is moving in the wrong direction if it concentrates purely on economic reasons.’

05/01/2006