No one escapes the hospital. Most of us spend their first days of life there, very many of their last weeks and months. In between decades, in which we are always dependent again on the hospitals – because of cruciate ligament tear, stroke, cancer. Or, at least, have confidence that you are in an emergency here to help. We all hope to find in the hospital healing and relief.
This hope is often disappointed. Patients and relatives feel when they see Doctors, nurses and orderlies go by, hasten, that in this place the Individual with his complaints and Fears, matters little. Again and again, avoidable scandals shook the confidence of the outbreaks of multi-resistant germs, the manipulation of waiting lists for organ donation recipient. Or the reports pair about the sometimes painful life-prolonging treatment of Dying that is more to the profit than to the Welfare of the doomed.
Individual cases, it is hoped. Where you have to self Doctors trust, it is different. Or not?
It is now the whole System is sick. So Germany is one of the most expensive health systems in the world, the latest therapies are available, but we die on average earlier than people in many comparable countries. Greece is not even half as much money per capita for health, but life expectancy is even higher there. Our clinic sector provides employment, high-tech and profits. However, in its actual product – the health – he remains under the expectations. Why?
As a result, approximately as many patients due to hip, knee surgery in Germany or back pain unnecessarily, while at the same time, the chronically sick, children and the elderly in need of urgent help, today, not to be dismissed, often in the emergency rooms? Almost nowhere in the world are so many and so well-trained Doctors and nurses. Nevertheless, the time for talks with the patient is missing.
The star has more than 100 physicians from all over Germany to find answers to with the assistance of medical doctors, clinic Directors, presidents of professional societies, and chambers of Physicians, with ethicists. Many are experiencing dramatic abuses of seven eye-witness accounts are documented here, with more to follow online on star.de. In the discussions the Doctors had driven by the constant concern that you can ensure the safety of their patients only with difficulty, if at all. From these conversations, in which so many complained of the same grievances, did the idea of the medical appeal. At the Doctors-appeal-track 5. In September, he had 215 signatories to, many major organizations have joined him. Since then, a growing number of supporters. The list with the undersigned Physicians find it here, you will be continuously updated.
The step to the Public, not many in the medical field is easy because it is risky. The senior physician Silvia Vieker about lost 2018 your employment at the Klinikum Bayreuth, after you publicly on problems with incorrect diagnosis and treatment in child neurology noted was that from their point of view passed (star no. 43/2018). Vieker says: “You can also earn even today in hospitals can easily be bread, but only under three basic conditions: Be blind, deaf, and mute.”
The flat is also close to Patient
Almost all of the star surveyed Physicians cited two causes of the misery: extreme economic pressure and the prior 16 years (and in its radicality international unique) system of payment for “lump”. For these “DRG” (Diagnosis Related Groups) diagnostics are grouped in “groups” and paid with a lump sum – according to the rule-of-thumb: the higher the effort, the more money. The fatal effect is that patients pay for themselves, no matter how sick you are – in this System, especially if you have many “procedures” are carried out. In the DRG-logic these are all the interventions of a syringe through the stomach mirror, up to large-scale operations.
Who searches the hospital for help, they do not know usually, such as the billing mechanisms of the DRG system may have an impact to his disadvantage. Jan Walz* was just glad to be out of his pain relieved. In a Hamburg emergency room Doctors had discovered urinary stones and give him a Rail in the ureter is pushed to dilate slowly. Two months later, Walz should come again, then, the stone shattered with shock waves and removed.
The week-long living with the Rail was bad. “In the case of any unwise move, I had the urge to pain and in the urine, blood in the urine,” says Walz. Today, he knows that he must afflict a maximum of 14 days. In uncomplicated cases there is no medical reason to have the Rail longer in the body. But a economic: as of day 31 it was the case for about 1400 Euro more.
It is a harmless example of the Spread of market-based interests to the most worthy areas of our life. In the worst cases, it’s a question of whether people spend their lives self-employed or disabled, and whether you may live or may die, or need to. So how, possibly, in the case of a 71-year-old Angela p.*, Up today your family asks why the cancer patient in the terminal stage, yet so long had to suffer. Technically, it was artificial respiration, you would have never wanted. An intensive care physician had pushed the tube into the trachea, although already a stroke, Arteries in both legs and a lung infection had weakened the terminally Ill more. Because his mother barely came to consciousness, the language of the authorised person son for you. He said: no life support measures. However, Angela S. died only four months later – after eleven operations. Massive Disincentives in the payroll system, be it having a bearing on such decisions, says the palliative physician Matthias Thöns, knows the case well: A day of breathing brings a hospital for seriously ill patients currently 25.495 euros, four days with 58.215 euros. For Angela S. was settled in the year 2017, the long-term ventilation package “A06A”: at that Time, the 207.648 Euro.
Just when complications make a case less profitable, it can save the lucrative ventilation, the balance sheet. Can long-term provisions themselves beat can cause a lot of complications: lung damage, a muscle-nerve disease, or an often-lethal bile suffering. Of course, it is also conceivable that the doctor, who blasted the ball into the breathing tube, did not want to give up on his patient just. Economically-driven decisions are very often in a grey area where Doctors from medical considerations, or otherwise could act. The statistics, however, the safe conclusion that they are highly effective.
The big money
Where is the pressure? In the 1990s, the Commodification of the medical journey began. Politicians feared at the time, a “cost explosion” in health care. And in fact, mismanagement prevailed at the expense of the contribution payers. Hospitals received a fixed amount for each day the patient spent – no matter how sick you were. They kept you there for a long time, especially over the weekend. The DRG System should protect patients from the danger: It should bring transparency, the Fund will keep contributions stable, and on top of that, the force in the international comparison to many hospitals in a cut-throat competition. “Nothing works better than the free market” – the neo-liberal creed paid homage to politicians across the parties. So CSU-Minister of health Horst Seehofer prepared for the introduction of case-based lump sums, the Green Andrea Fischer took you, the SPD-Mrs Ulla Schmidt cemented it. In the micro-cosmos of many hospitals, the development can be seen today the fact that commercial Directors are the medical pre. Economists, however, are not obligated to the medical Ethos. To your success, so the System wants to it is based on Numbers. It is not villainy at all, but merely of course, is that Economists read the DRG-catalogue exactly how tax provisions, with the aim of you be designed to that your company a lot of money.
And so, more and more “cases” in the same time treated. The more, the more revenue. Since the introduction of the lump-sum the number of hospital treatments increases steadily, it is a Europe-wide unique development. So it is that in Germany, more Doctors than in other comparable countries. However, they have per “case” in the least amount of time. This scarce Good you don’t want to waste as far as possible for income weak conversations with patients. The often correct to Wait and Think about the best therapy, according to this logic, the time lost: is Rewarded in the DRG-System activism. To 40,000 procedures, the catalogue is called, you will be charged on a complicated way to total compensation, including factors such as diagnosis, disease severity, or age to be incorporated. No doctor understands how exactly. If a procedure is done, it must be immediately documented. A new profession soon emerged after the introduction of the DRG system: “encoder” search in massive procedures catalog after each digit, which can be settle. Only nothing is overlooked, and not a Cent to little bill. Also the equips in the struggle to find the money natural adversary of the hospital coder, the Medical service of the sickness funds, with such specialists is high, it will always be more. Each other they create each other’s work, such as the tax officer to the tax adviser.
With sugar bread and whip your physician in this combat zone Director tractable. With widespread bonus contracts you corrupt Doctors, especially those in senior positions: pre-create The more lucrative patients, the higher their special payments. Tumor sick, for instance, are rewarding. So is it that even in times of great progress in cancer therapy, still, many patients come in by the German cancer society certified centres, but in provincial hospitals, where Doctors have little Routine with the sophisticated surgical procedures and treatment regimens. It can cost, in extreme cases, years of life. Even subtle blackmail acts do not Provide the chief doctors shall be deleted in their departments. “Then we are all in a Team, fear of more work, and think about how you can generate revenue,” says Justus Hilpert, the former head of an intensive care unit.
“The economic logic undermines this System, the medical logic,” says the Freiburg medical ethicist Giovanni Maio. Rewarded not careful, but the current line-shaped doctor, the Assembly line will proceed fast. “The doctor learns to classify patients in the emergency Department only after the medical need, but if you promise to win.” The Insidious thing is: no one expressly States to think so. “The doctor himself says, to need this provision to make.” Maio castigates this as a “moral deformation of the Doctors”.
How often have Physicians, “” deformed, hardly anyone knows exactly how the Bremen-based ethicist, and physician, Karl-Heinz Wehkamp. He has researched, together with a former clinic Director. The two traveled through Germany, and dozens of Doctors, and managing Director, asked, anonymous, how often do business requirements affect medical decisions. “The Director denied any such influences, whereas almost all of the Doctors they felt. Many spoke of “consistently”, says “daily” at “every Visit” or “always more,””, Wehkamp. “Not a few suffer and try to fight back, but it’s not always.” So two-thirds of operations reported no real need to ask the heart catheter measures worthy, gut level rise and prolonged artificial beat. The majority of the Doctors gave to patients included, the “include to go to the hospital” to get more “cases”.
Because the more cases, the more secure the Survival of the clinic. “There was a secret Agenda behind the introduction of case flat-rates”, says Günther Jonitz, President of the chamber of Physicians of Berlin, fought against the DRG-System. “Because no local politician dares to close the small clinic in front of its own door-to-door, it should inform the competition.” The competition, a faceless idol, under whose Auspices the eliminated unprofitable work at the end of self.
In fact, the States of drive hospitals into the red, by withheld from you for years money for investment. In Germany, another national exceptionalism, are the countries for construction work and the purchase of such medical devices are responsible to the funds for all costs related to patient care. Due to the state Schmalhanserei the hospitals Finance today, however, many of its infrastructure investments from the flat rate system is illegal. For you to save staff, for whose salaries the packages are meant to be. More than a third of the clinics is now in the hands of private institutions – those financed from the lump-sum payments in addition, the yield expectations of the shareholders.
The supporters of the Doctors of appeal are unanimous: it can’t go any further. An emergency stop must be found. Long ago, the physicians are forming for concerted resistance, ahead of the German society for Internal medicine with a Doctors code, “medical Economics,” the 30 organisations in droves. This code and other opinions of high-ranking institutions were the template for the Doctors appeal. The code calls on Physicians to economic targets to oppose, if they violate the patients ‘ welfare. Makes a full appearance, but it is questionable whether the Doctors still have enough Power to change the System from the inside out. The Berlin-based health economist Alexander Geissler thinks more. “Hospitals should be independent of case-base amounts to get all of what is previously shown poorly in the payroll system.” Would benefit on the one hand, large hospitals, if you provide a lot of heavy, yet bad cases, and patients are rewarded with rare diseases. And the small district hospital for an underserved Region is important for survival, “and then it would generate less pressure on hospital cases, and to generate revenues through the treatment of highly complex cases for which it is not at all suitable”.
Nearly 2000 hospitals in Germany – on the number of inhabitants in a tip-related international value. About 800 to 1000 were superfluous, according to estimates, which is currently argued a lot. Where today three small competing hospitals close to patients, one could eventually build a larger center, the released would be used at the end of staff urgently. However, such a strategy requires a long breath – and a willingness to invest. As a model for Denmark, the following applies: There was developed in the early 2000s, a master plan, new hospitals were built where there were none before, the rescue service was re-established that organized care differently. Result: Today houses the Danish 25 great sick. In Germany there is no such Plan, the hospital landscape has grown over the decades in the wild. And what would happen if politicians would now follow the loud call for hospital closures, without having to worry about the wrong incentives? There is then, only with fewer clinics. That would be disastrous.
For the Berlin chamber of physicians President Günther Jonitz is clear: “You have to think the health care system is quite new, and the high economic pressure to bring an end to it.” A model may have in mind Jonitz, has existed in Germany since the year 1884: It is the System of the professional associations – the statutory accident insurance. Unlike the health insurance you oriented your payments in mind, what is the cost of drugs, personnel, hospitals and doctor’s offices, but how quickly patients get back on their feet. Because of the work ability of the individual accident victim is attached to for nearly a century and a half such a high value, it is to establish “all appropriate means”, – stated in the social code book VII. is Quite different with a Central Passage sounds, in contrast, its sister act, the code of social law book V, which determines the everyday life of “ordinary” hospitals. It reads: “The services must be sufficient, appropriate and economic; you are not allowed to exceed the dimension of the Necessary.” The daily life reflects it: “Everything comes from a Hand, all working on a goal,” praises the doctors President of the chamber, Jonitz, the professional Association of supply structures.
Maybe you could come closer with such a System an Ideal, is not the lack of incentives and greed of the health care dominate, but only one goal: the healthy Patient.
*Name changed by the editors
Here Doctors report on the economic pressure they are exposed to in clinics:
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