Financing hospital innovations in Germany Marc Schreiner German Hospital Federation
German Hospital Federation Representative organ of all German hospitals, no mandatory membership 28 member organisations (16 hospital federations on state level, 12 association on the federal level for each special type of ownership, e.g. different churches, universities, municipalities and counties, private for profit companies, pension funds, etc.) Partner of politics on national, European and international level Key player in the self-government-system of the German health care sector (e.g. in the Federal Joint Committee) Development of the German DRG-System Provision of services to member organisations
Key facts German hospital system 1.980 hospitals (three types of ownership: public, charity based, private for profit), almost 500.000 beds 1,2 million employees (850.000 full time equivalents) 140.000 doctors, 300.000 nurses 18,8 million inpatient services, 20 million ambulatory services Income of 90 billion Euro annually (DRG-based financing system for the costs of the treatment, paid for by statutory and private health insurance funds; grants by states for the costs of investment and contributions by patients) All German hospitals have to deliver their services under the same conditions (legal framework, quality standards, working conditions, reimbursement system, etc.) The patient has the free choice and access to all hospitals
Hospitals On the same legal basis Same quality standards Reimbursement under the same conditions Open to all patients Same working conditions Same admission standards
Index (2000 = 100) Index (Year 2000 = 100) Hospitals by ownership 140 (3) public charity based private acute care hospitals 120 2008 571 673 537 100 hospitals 2009 554 661 565 2010 539 644 575 80 60 180 140 100 60 2000 2002 2004 2006 2008 2010 2012 2014 2000 2002 2004 2006 2008 2010 2012 2014 public (1) charity based (2) private (3) beds (2) (1) 2) ( (1) (3) 2011 529 635 572 2012 510 603 579 2013 2014 500 494 591 581 577 571 beds in 1.000 2008 2009 2010 2011 225,5 223,6 223,4 221,5 167,9 165,7 164,3 163,1 71,0 73,9 74,7 76,4 2012 217,9 161,6 78,9 2013 218,0 160,2 78,5 2014 217,5 159,2 78,9 Dezember 2015 Source: Federal Statistics Agency
Index (Year 1991 = 100) Key facts summary summary: development course key data of german hospitals (2) 120 100 (3) 80 60 (6) (1) (5) (4) 40 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 beds (1) number of cases (2) occupancy rate (3) lenght of stay [days] (4) occupancy days (5) hospitals (6) Dezember 2015 Source: Federal Statistics Agency
Hospitals in the region Concentration of hospitals
Index (Year 2000 = 100) SHI Companies Expenses hospitals physicians dentists pharma bil. EUR bil. EUR bil. EUR bil. EUR allocation (2014) and development of SHI-expenses others 23,7% pharma 17,2% 2003 46,31 23,33 8,03 23,40 2004 47,17 21,86 7,59 21,13 2005 48,53 21,95 7,50 24,67 2006 49,93 22,69 7,67 25,10 2007 50,42 23,55 7,85 27,04 2008 52,14 24,65 8,01 28,39 2009 55,42 26,39 8,19 30,00 2010 58,13 27,09 8,30 30,18 2011 59,95 27,63 8,47 28,98 2012 61,66 28,25 8,67 29,20 2013 64,19 31,43 9,51 30,09 2014 67,86 33,43 9,83 33,36 180 160 140 120 100 80 dentist 6,9% physicians 16,4% 2014 hospitals 35,0% 2000 2002 2004 2006 2008 2010 2012 2014 (1) (4) (2) (3) inpatient treatment (1) physicians (2) dental (3) pharmaceutical (4) Dezember 2015 Source: BMG
Index (Year 2000 = 100) PHI Funds Expenses hospitals physicians dentists pharma bil. EUR bil. EUR bil. EUR bil. EUR 2000 4,7 3,2 1,9 1,3 allocation and development of PHI - expenses 2001 4,8 3,4 2,0 1,4 2002 4,8 3,6 2,1 1,5 2003 4,9 3,8 2,2 1,7 2004 5,0 4,1 2,3 1,7 2005 5,2 4,3 2,4 1,8 2006 5,4 4,5 2,5 1,9 2007 5,6 4,8 2,7 2,0 2008 5,8 5,1 2,9 2,2 180 140 (3) (4) (2) (1) 2009 6,1 5,3 3,0 2,3 2010 6,4 5,5 3,2 2,4 100 2011 6,7 5,6 3,4 2,4 2012 6,7 5,7 3,6 2,5 2013 2014 7,0 7,1 5,9 6,0 3,7 3,7 2,6 2,7 60 2000 2002 2004 2006 inpatient treatment (1) dental (3) 2008 2010 physicians (2) pharmaceutical (4) 2012 2014 Source: private health insurances federation
BW BY BE BB HB HH HE MV Ni NRW RP SL SN ST SH TH Euro 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 Subsidies granted by states State Baden-Württemberg (BW) Bayern (BY) Berlin (BE) Brandenburg (BB) Bremen (HB) Hamburg (HH) Hessen (HE) Mecklenburg-Vorpommern (MV) Niedersachsen (Ni) Nordrhein- Westfalen (NRW) Rheinland- Pfalz (RP) Saarland (SL) Sachsen (SN) Sachsen-Anhalt (ST) Schleswig- Holstein (SH) Thüringen (TH) Total subsidies Mio. Euro % 410,0 14,73 500,0 17,97 106,5 3,83 104,8 3,77 38,6 1,39 137,5 4,94 241,5 8,86 55,8 2,01 258,9 9,30 10.000 492,3 17,69 119,8 4,30 28,6 1,03 6.000 101,0 3,63 4.000 47,9 1,72 90,1 3,24 50,0 1,80 development of the subsidies (1991 = 100) 130 110 100 90 70 60 40 0 Dezember 2015 2.783,2 100,0 Source: survey conducted by the hospital working group of the states health authorities
DRG-System DRG Diagnosis Related Groups (Fallpauschalen) Introduced by 2004 as an opt-in, now it is mandatory One flat fee for the whole treatment From the admission till the discharge of the patient All costs are covered The system is developed continuously
DRG-System DRG Diagnosis Related Groups (Fallpauschalen) To each case a single DRG is allotted. In 2015 there were about 1.200 DRGs existing. Beside the partition into a major diagnosis and sub-diagnosis the length of stay and the complexity factor can be accounted for. With using a so called Grouper -software a specific case-related relative cost-weight can be calculated. Finally the cost-weight is multiplied with the respective state base-rate. Excursion added fees: European Reference Networks
Funding of innovations Innovations are taken into account systematically Operational codes and classifications are permanently amended Finally the relative weights are adjusted, if the innovation is accepted to be included Problem: about 3 years for calculation and acceptance NUB Only on application by the hospital in the course of a strictly regulated procedure and acceptance be InEK Only for one year Has to be negotiated on the local level
Funding of innovations 37.246 cases Drugs and medical devices, e.g.: Treated stents with bio-active surface Co-growing heart valve Drug releasing, completely reabsorbing coronary stent In 2014: 115 Million Euro
Further innovations New funds on research on innovation 300 Million Euro annually from 2016 to 2019 New models of providing healthcare (225 Million Euro) Provision of care in rural areas Providing care by means of e-health and telemedicine Health services research (75 Million Euro) Fostering quality and patient safety Improving economic efficiency in the healthcare system
Investments in German health economics
Thanks and contacts German Hospital Federation Director EU-Policies/International Affairs Wegelystraße 3 10623 Berlin Phone: +49 (0)30 39801 1030 Fax: +49 (0)30 39801 3011 Mail: m.schreiner@dkgev.de Internet: www.dkgev.de