Clinic boss on Lauterbach’s reform: “Roll backwards into the 20th century”

FOCUS online: Health Minister Lauterbach wants to reform the hospital system. A good idea?

Andreas du Bois: It is undisputed that we need reform, because we really do not have a particularly efficient system. It is very expensive and seems only partially prepared for demographic developments.

Why is that?

wood: There was never a master plan, but rather it developed more or less without any content-related specifications in terms of quality and structure. Our healthcare system was originally intended as a cost reimbursement system, then the privatization phase came in the 1980s and 1990s. Suddenly the system was supposed to generate a return, and that return was taken out of the system by shareholders – but that’s not what it was designed for.

A purely market-based system meets a system that is heavily influenced by planning and with fixed budgets. It has little to do with the market economy when successful clinics largely have to give up additional revenue and lower revenue from less successful hospitals is compensated for.

Are you talking about the university hospitals?

wood: Yes, take them: They produce hundreds of millions of deficits and that is simply compensated for by the state, which means that the managing directors of the university hospitals have tens of millions of our tax dollars at their disposal – that is simply incredible, especially when there are other hospitals on the other side, such as the non-profit ones , have to earn every euro themselves.

“The risk of being punished by voters is high”

Why hasn’t politics intervened so far?

wood: No politician dares to close a hospital in his constituency or to oblige hospitals to cooperate in the context of necessary structural adjustments. The risk of being punished by voters is high.

Any closure of a hospital prompts immediate protest and demonstrations – although most of the protesters would never go to the hospital about to close if they became seriously ill.

And now the situation is getting worse?

wood: Yes, because for years payers have only ever reimbursed about half of the cost increases in hospitals. So: If the nursing staff got four percent more wages and the material costs went up, the carrier shot two percent more.

The situation was similar with the investment costs, for which the federal states were responsible. An investment backlog has been built up here that the clinics can no longer compensate for.

The result is now that an estimated two out of three clinics are no longer economically healthy. Something must therefore be done urgently, otherwise the supply will collapse in entire regions.

There is also a dramatic demographic development: baby boomers are becoming pensioners and pensioners are becoming patients. But there are no more skilled workers below. It is estimated that by 2030 we will be short of 400,000 nurses and 70,000 doctors. That means we need reform, but one that is based on people’s needs and the quality of treatment.

But then it’s good that the Minister of Health is finally tackling it.

wood: Yes, if you mean our health minister in North Rhine-Westphalia. But no, if you name the federal health minister. What the federal government has now announced is just poorly thought out and designed to ignore reality.

Lauterbach’s hospital reform comes in a hurry – without practicality

How come?

wood: Lauterbach came at the end of last year with one of his hasty shots and wanted to turn the hospital organization upside down in a hurry. He had rounded up 16 scientists who were to develop a new concept in a few weeks. Expressly, without involving the practitioners from the countries and those affected. This is how a typical paper from the green table came into being – without any practical suitability. It wasn’t even checked.

And that’s no good?

wood: In the Lauterbach paper there are definitely good aspects, for example the financing of emergency care that no longer follows the current number of cases. In addition, however, many aspects are unspeakably unrealistic and would endanger the health care of many population groups.

The basic principle of the reorganization in the Lauterbach paper is a classification of all hospital locations into so-called Levels I to III. These are primarily geared towards emergency care. A hospital moves from Level I to Level II if it has, among other things, a delivery room, a heart catheter measuring station and a stroke unit. Structural features are linked here that initially have nothing to do with one another and are not mutually dependent. How should the delivery room help with a stroke, like the heart catheter with a twin birth?

Sounds illogical. . .

wood: And it gets even worse: The levels created in this way are assigned to treatment groups. For this purpose, medicine was divided into a catalog containing more than 120 service groups, such as childbirth, treatment of diabetes, stroke, breast and colon cancer operations, etc..

Many operations and treatments are only permitted above a certain level, Level II, for example, obstetrics, cancer treatment and complex abdominal surgery.

Reform is particularly fatal for specialized houses

why is this bad

wood: Because the linking of structural features from emergency care has nothing to do with the requirements of modern medicine in other areas. Especially in the urban centers, clinics have specialized and created structures that are necessary to treat specific requirements particularly well. Mention should be made here, for example, of the treatment of cancer in designated centers or premature births in perinatal centers or joint replacements in designated endoprosthetics centers.

As part of this specialization, many of these hospitals have deliberately dispensed with other subjects that can then be found in the neighboring hospital – this led to the concentration of cancer medicine, obstetrics and many other parts of medicine.

In this way, they were able to pool resources and meet the increased demands of modern medicine. The Lauterbach reform is a scroll backwards into the 20th century.

Now a house has to provide everything again – for example a delivery room, even if the number of births is not sufficient to train the midwife team.

What does that mean practically?

wood: Take our house in Essen. At one of our locations, we are very specialized in cancer treatment and, among other things, house the largest breast cancer center in Germany.

This type of specialization has been expressly demanded and promoted in recent decades by professional societies as well as patient self-help groups. Similar centers have emerged in many cities in North Rhine-Westphalia. The twelve largest breast cancer centers in North Rhine-Westphalia together treat around 7,000 patients with breast cancer every year, which is half of all patients in NRW.

If the Lauterbach reform were to come as planned, only Level II hospitals would be allowed to perform breast cancer operations. That means that all of these twelve breast cancer centers would also need a delivery room, a stroke unit, for example. I wonder what is this good for?

“This would collapse our entire health system almost overnight”

What would be the result?

wood: Only two of the twelve breast cancer centers with Lauterbach Level II equipment would remain, and 90 percent of the patients would no longer be able to be cared for.

Since obstetrics would also be tied to Level II, more than half of all pregnant women would have to look for a new hospital and could no longer give birth in the clinic of their choice. Of the approximately 350 hospitals in NRW, 36 remained on levels II and III, which are allowed to do births, cancer treatment and complex abdominal surgery.

Our entire healthcare system would collapse almost overnight. And what for? Why do obstetric clinics need a stroke department and a heart catheter center?

What does that have to do with each other? Without discussion with those affected and without any awareness of what it means, the Lauterbach Commission rushes out a paper that cannot be implemented remotely.

How could it be better?

wood: Health care is primarily a state matter and in North Rhine-Westphalia Health Minister Karl-Josef Laumann has been working on the issue since 2019. He got everyone involved on board and developed a reform project that is geared to the needs of the people and the regional conditions. In essence, it is about the real need, i.e. how many cases of which disease are there. For each ability group…

… so for every kind of therapy. . .

wood: … yes, qualification criteria were defined for each performance group in terms of equipment, training and experience. The hospitals can apply for the service groups, and the service groups are mapped where the best structures and the greatest know-how are – while maintaining regional care.

If there are too many applicants for too few cases in a region, some will not get a chance. Namely those with the least experience or the least suitable infrastructure. In this way, unnecessary double structures are removed and a cleanup takes place, which will hopefully also alleviate the lack of specialist staff.

Cooperation between the federal and state governments is necessary

If I live in the country, am I at a disadvantage?

wood: No. Accessibility also played a role in the distribution of performance groups. A hospital can be reached within 30 minutes.

So Laumann instead of Lauterbach?

wood: Laumann has set up a long overdue and sensible process. The best would be Laumann and Lauterbach, that is NRW as a model region and supplemented by the positive aspects of the federal government. Under no circumstances should the federal government impose an impractical reform on the states from an ivory tower and without taking regional conditions into account.

It is therefore correct that NRW, together with Bavaria and Schleswig-Holstein, has commissioned an expert opinion which, as a result, confirms the position of the states, which is: Lauterbach has exceeded its competences here. Lauterbach has slowed that down, at least for the time being.

I very much hope that we can now continue our work in NRW in peace and that in a few years the experiences with our model can serve as the basis for a constructive discussion with the other federal states and the Federal Ministry of Health – whoever will then be the Federal Minister of Health.