Caroline Wagner: Large versus small hospitals

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In this slideshow, Dr Caroline Wagner, Research Fellow, Scientific Institute of Techniker Krankenkasse (TK) for the Benefit and Efficiency in Health Care (WINEG), Germany, draws on case studies in …

In this slideshow, Dr Caroline Wagner, Research Fellow, Scientific Institute of Techniker Krankenkasse (TK) for the Benefit and Efficiency in Health Care (WINEG), Germany, draws on case studies in Germany of large and small hospitals to discuss whether either is better.
Dr Wagner spoke at the Nuffield Trust European Summit 2014, which was supported by KPMG.

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  • 1. Big Hospitals versus Small Hospitals - is Either Better? European Health Care Summit: Future organization of hospital services 21 January 2014 | Nuffield Trust, Brussels Dr. Caroline Wagner
  • 2. Statutory Health Insurer: Techniker Krankenkasse • Founded 1884 in Leipzig for technicians • 8,68 million insured - currently largest SHI • Annual growth (2013): + 284,000 insurants • 12,857 employees and 247 branches • Total Budget: 21,3 billion EUR • 27% for hospital care (5,7 bil. EUR ) Increase of 9.3 % (2013 to 2014) • Compulsory uniform contribution rate for all statutory health insurers: 15.5% of tax income up to 4.050 Euro  7.3 % borne by employer  8.2 % borne by employee
  • 3. Statutory Health Insurers in Germany are public bodies - but self-administered Private Company Public Body with Governmental Body Self-Administration For-Profit Health Insurer Statutory Health Insurer Ministry of Health 1994: 1,162 2004: 280 2014: 132 Reduction of statutory health insurers: 89% in the last twenty years
  • 4. Mix of Public and Private Health Insurance Private Supplementary Health Insurance Statutory Health Insurance 70.2 Million SHI Insurants = 89% Possibility to opt out for employees with an annual income more than 48,600 € Statutory Long Term Care Insurance Private Health Insurance 8.5 Million Insurants = 11 % Private Long Term Care Insurance
  • 5. Players: Statutory Health Insurance - Health Care • Service guarantee • Mix of collective and selective provider contracts Health Care Provider Market • Free choice of insurer • Open enrolment • Income related contribution shared between employer and employee • Free co-insurance for family members • Risk adjustment • Comprehensive benefit package • Benefits in kind Insurers Health Insurance Market Care providers Regulatory framework • Federal government • State governments • Joint self-government of insurers and providers Insured • Free choice of provider • No enrolment with GPs • Small Co-payments: e.g. hospital care 10 EUR per day up to 28 days
  • 6. Statutory Health Insurance Expenditures in Germany Largest Share: Hospitals Dentist, 7% 1. Hospitals 2. Pharma 3. Physicians 4. Dentist 60 bil. EUR 30 bil. EUR 28 bil. EUR 12 bil. EUR Physicians, 16% Hospitals, 36% Pharma, 17% Others, 24% Source: Ministry of Health
  • 7. Dual Funding of Hospitals 1. Statutory health insurance funds and Statutory health insurance funds bear the running costs i.e. via renumeration of the provided health services 2. Federal states "Bundesländer" Federal states finance capital investments based on state hospital plan State subventions for new building possible via investment programmes Subventions vary by state Dual funding sources for hospitals = separation of decisions about capacities and responsibilities for costs 7
  • 8. Basic Types of hospitals in Germany 1. Acute hospitals (including university hospitals) 2. Prevention and Rehabilitation hospitals Follow-up care and after surgery care Rehabilitation and prevention No contracts with statutory sickness health insurers 1.233 facilities (2011) 3. Psychiatric hospitals Traditionally specialised in psychiatric treatments Psychosomatic medicine Now also often covered by acute hospitals 8
  • 9. Interlocking of inpatient and outpatient sector • 1993 Gesundheitsstrukturgesetz i.e. Health Care Structure Act) Opening up of the hospitals for outpatient surgery Improvement of collaboration primary care and hospital physicians Currently 1,247 hospitals with ambulatory operations • 2003 GKV Modernisierungsgesetz i.e. Health Care Modernisation Act New contracts options: outpatient treatments in hospitals, particularly disease management programmes, chronic diseases • 2007 GKV Wettbewerbsstärkungsgesetz i.e. Competition Fortification Act Simplification of access to outpatient treatments concerning highly specialised care and complex as well rare diseases • 2012 GKV Versorgungsstrukturgesetz i.e. Structure Provision of Care Act If co-operation exists, statutory oupatient doctors are entitled to undertake ambulatory treatments and operations in hospitals 9
  • 10. Number of Hospitals in Germany 1992 - 2012 2,250 2,200 2,150 2,100 2,050 2,221 2,197 2,166 2,139 2,104 2,087 2,083 2,084 2,064 2,045 2,000 2.017 1,950 1,900 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Source: Federal Statistics Agency
  • 11. Beds, Utilisation, Cases and Length of Stay Years Beds (million) Utilisation (%) Cases (million) Length of Stay (days) 2002 547.3 80 17.4 9.2 2003 541.9 78 17.3 8.9 2004 531.3 75 16.8 8.7 2005 523.8 75 16.5 8.7 2006 510.8 76 16.8 8.5 2007 507.0 77 17.2 8.3 2008 503.4 77 17.5 8.1 2009 503.3 77 17.8 8.0 2010 502.7 77 18.0 7.9 2011 502.0 77 18.3 7.7 2012 501.5 77 18.6 7.6
  • 12. Hospitals in Germany by Ownership Public 2012 24% (601) 2002 33% (817) 1992 Charity based 28% (719) 44% (697) 34% (877) 43% (1062) 0% Private 37% (950) 33% (527) 23% (369) 50% 100% Source: Federal Statistics Agency
  • 13. Hospital Market in Germany - Size Number of Employees Number of Hospitals Turnover (m EUR) Fresenius/Helios 70.000 117 5.500 Asklepios 34.000 150 2.980 Sana 26.000 48 1.790 Rhön 15.000 10 1.000 Schön 8.500 17 591 Paracelsus 4.800 29 345 Municipal Leader: Vivantes (Berlin) 14.391 100 900 Charitable Leader: St. Franziskus-Stiftung (Münster) 11.212 13 645 Private Leaders: 13
  • 14. Thank you for your attention www.wineg.de