Restructuring the healthcare system: Rethink rather than rearrange

What exactly must happen so that good medical care can be provided offered in the future also? Will it be sufficient to modify the existing in-patient and out-patient care? Not really, thinks Prof. Dr. Dirk Sauerland, Dean of the Faculty of Economics and Society at Witten/Herdecke University. The economist's areas of expertise are institutional economics (i.e. examination and organization of incentive systems) and health policy, but for the moment his interests lie in evaluation of new forms of care.
His summation of the current developments in healthcare: In principle, care must be rethought, not merely adapted. He explains why in an interview with VIEW. And especially: To what extent.

Privatization, switching of services to an out-patient basis, development of supply chains: These keywords sound like disruptive changes in healthcare. Are they really so?

Prof. Dr. Dirk Sauerland: I think that these buzzwords are only the tip of the iceberg and that we still need many far-reaching changes. Privatization or the takeover of practices by investors and large commercial chains, to mention just a few. The fact that this happens at all in the succession of practices is because owners of registered private practices who want to retire are only now having difficulty finding parties interested in buying. In the past this was no problem, since selling the practice to the younger generation was planned as part of financial security after retirement from the practice. Now, however, the needs of young medical graduates have changed. In fact, the situation is that fewer and fewer medical graduates want the financial and time burden of buying their own practice. Thus it is difficult for physicians who are now retiring to pass on the practice to successors who intend to buy into the old structures and profit financially from them. This also explains the 5,000 to 7,500 open positions in the area of registered private practices. Obviously some over-served regions still exist. In contrast, however, a growing number of regions are under-served.

Entirely new concepts are needed if good GP care is still to be guaranteed. We do not have to spend our energy to preserve existing structures. We should adapt the structures to the needs not only of the patients but also of the service providers.

How would this look?

Prof. Dr. Dirk Sauerland: GP care must be duly considered as early as the city planning stage. Municipalities must decide as early as during neighborhood planning where and which physicians are needed. This is linked to the truly important question about the organizational forms in which we want to picture the necessary care structures. When we know that it is no longer attractive for young people to take on the financial risk and time commitment that accompanies their own practice, we need new organizational forms. 

Medical care centers are one possible alternative for modified working models. As to the question of who should then be the sponsor of a medical care center, the municipalities should also take on greater responsibility in that respect. The legal form of the cooperative institution in which the municipalities participate could be one possibility for sustainably ensuring care. In the matter of housing, cooperative institutions are successful private organizations where risks are spread among many parties and sustainably managed. Why can't this therefore also be done in healthcare?  As an economist, I'm not critically opposed to privatization, considering that practices have already been privately owned in the past. However, we are considering the choice of organizational forms that work sustainably – and do not focus primarily on the return on investment. 

Could such new concepts be helpful in achieving the goal of a greater switch of services to an out-patient basis, as set forth in the hospital reform project.

Prof. Dr. Dirk Sauerland: Yes, and we urgently need this switch of services to an out-patient basis. In an international comparison, we have very many hospital cases in Germany. This is not surprising, since we also have a very high bed density per 1,000 inhabitants. It is evident, however, that the quality of care is not better as a consequence. A current study in New England Journal of Medicine proves this for hip operations: Whereas patients in the USA spend only one day in hospital but in return receive more intensive and more stringent preoperative and postoperative out-patient care at home, people after hip surgery in Germany spend approximately ten days in hospital and 230 days in rehab. According to all data published in the study, however, no differences were found in the quality of care. Service providers in the USA have better incentives to offer sustainable care solutions.

Then do we currently have the out-patient structures for such a concept?

Prof. Dr. Dirk Sauerland: No, and that's my main point. We can't implement new concepts simply on the basis of existing structures. The point is that we must rethink the health system, as has already long been needed. This includes abolishing the strict separation in the billing of out-patient and in-patient services. Our current system is not even designed such that logical transitions are possible, because such are not reflected in the billing logics of the separate sectors. The current study from the USA shows that, for example, flat rates for service providers require more coverage, and even out-patient care before and after hospitalization must be considered.

For this, it is important in turn to see how care is organized locally. I can imagine, as I said, that out-patient care will be geared more closely to municipal districts and demand structures. Regardless of our competitive law: What argues against a municipal district's appointing a single nursing care service provider on a bidding basis? That party would then have shorter distances, fixed routes and closer relationships with the population. Cities also designate school districts on a bidding basis. Why not also nursing districts?

Isn't this somewhat radical?

Prof. Dr. Dirk Sauerland: I would love just one time to put such a project scientifically under the microscope. If we don't trust ourselves to rethink the matter fundamentally, then we won't achieve any transformation but instead will impose new legislation on inadequate structures.

What would such changes mean for patients, and which role would digitization play in the process?

Prof. Dr. Dirk Sauerland: Digitization naturally plays an important role. Just as in Scandinavian countries, we need a central data location that all caregivers can access. Precisely for the German population, this would be a great challenge in the matter of data protection. And industry must provide appropriate interfaces, so that different systems are able to access this data pool. 

If care structures are changed, this would be difficult mainly for older patients. It would be easier for younger people. We can compare this with the development of banking: Whereas older people still withdraw cash in the local branch, many young people have not yet seen the inside of a bank branch. We can communicate more easily to them that, for example, a community nurse at the health kiosk will be the gatekeeper in future for the course of care, by analogy with Scandinavian structures. And that not every hospital offers all medical services – although in case of need a good hospital is readily reachable.

But there is still one sensitive issue: The concern that care will deteriorate if departments or institutions are shut down is definitely very great.

Prof. Dr. Dirk Sauerland: If such shutdowns were to be made on the basis of a demand plan, as is indeed envisioned in the new hospital plan of North Rhine Westphalia, this would be wrong. In Australia, the hospital density relative to the area is not so high, but nevertheless the population there receives very good care. Many hospitals, precisely in densely populated areas, are named after mayors and are absolutely unnecessary for medical care in the region. The situation today is such that empty beds are rationed, because the demands placed on hospital operation sometimes can no longer even be met. Three specialist physicians per ward and the existing lower limits on nursing staff represent an insurmountable hurdle for many hospitals, because sufficient personnel to meet these requirements are simply not available. Let us please continue to talk openly about the problems of changing demographics with ever fewer personnel but with simultaneously ever increasing care situations, so we can search for good solutions. In this way everyone benefits, especially the patients.

Many thanks for the interview.
 

About Witten/Herdecke University

For 40 years, Witten/Herdecke University has been offering talented young people study courses with a future in the areas of economic, politics, society, psychology, nursing, medicine and dentistry. The mission is to participate actively in shaping the social, ecological and economic changes of society – and to do so sustainably and equitably.