Interview
“Treatment in specialized centers significantly increases the survival rate”
The health economist Prof. Dr. Reinhard Busse from the Technical University of Berlin is very familiar with medical care in Germany. Here he explains why the system could be much better, whether the hospital reform is helping - and why the delay in digitalization has other reasons than expected.
The future is integrated care. Prof. Dr. Reinhard Busse knows what this means and how incentive and financing systems need to change for this.
Professor Busse, at first glance, we in Germany can be satisfied with our healthcare system. Anyone who is ill is treated – at least reasonably promptly. How do you see the situation?
Prof. Dr. Reinhard Busse: Unfortunately, I do not share this optimism. We have very high costs in Germany – but we get little health in return. On behalf of the Federal Ministry of Health, we analyzed eight comparable countries, including Denmark, the Netherlands, Belgium and France. It turns out that in absolute figures, we spend similar amounts to Switzerland – significantly more than the other countries – and at the same time achieve worse results. Germany is one of the countries with the highest rates of preventable mortality. A well-functioning healthcare system could prevent these deaths.
What exactly do you think is behind these poor results?
We admit too many patients to hospital instead of treating them as outpatients. In international comparison, Germans top the league for the number of hospital stays and also for the length of stays. Other countries have long since created structures that rely more on outpatient care.
Which illnesses could be treated just as well or even better on an outpatient basis?
Take high blood pressure or diabetes, for example. These illnesses are very well treated on an outpatient basis in other countries, so that patients hardly ever need to go to hospital. The number of inpatient treatments per cancer patient is also much higher than in other European countries. We have structures here that are rarely questioned. We could save an enormous amount of resources. And only those cases that cannot be treated differently would come to the hospital. These patients would then receive better care because doctors and nurses would not be so overburdened. The keyword here is integrated care.
Integrated care – what does that mean in concrete terms?
Integrated cross-sector care would mean that patients are treated in the way that is best for their individual case. In our system, there are rigid dividing lines: either a service is provided on an inpatient or outpatient basis, and often there is little exchange between these sectors. Integrated care would break down these boundaries and place the patient at the center.
“Actually, everyone prefers to be able to sleep at home – even those undergoing acute cancer treatment.”
For example, medical professionals from the specialist and primary care sectors could jointly decide whether a therapy can be continued on an outpatient basis or whether an inpatient stay is more appropriate. Such a system would be much better for chronic patients in particular, because they would not be sent from one facility to the next, but would be cared for in a structured care network. Also, everyone, even those undergoing acute cancer treatment, would prefer to be able to sleep at home.
Are there good examples of this integrated care in other countries?
Denmark, for example. The interfaces between outpatient and inpatient care work very well there. The emergency rooms of the hospitals largely treat outpatients, and only about 20 percent of patients are admitted as inpatients. In Germany this percentage is over 40. For chronic illnesses, we need some kind of case management where general practitioners take control and refer patients to specialized centers or clinics as needed. We currently have a serious problem: only some of the patients in Germany are treated in certified centers. This impacts survival rates.
What are the consequences of not being treated at a specialized treatment center for a serious illness?
Certified treatment centers are set up for specific illnesses, such as cancer. The German Cancer Society awards certification to hospitals that meet strict requirements – for example, in terms of the team from the fields of oncology, surgery and radiotherapy. The specialist nursing staff must also have experience with the type of cancer in question. In addition, research plays a special role: in certified cancer centers, treatment is not only carried out at a high professional level, but is also closely monitored scientifically. This ensures that the medical profession remains up to date with the latest medical findings and often has the opportunity to test new therapeutic methods at an early stage. Patients benefit directly from this. Studies show that the chances of survival are significantly higher in specialized centers that have access to the latest research results and studies. For example, a woman with breast cancer has about a quarter lower risk of dying if she is treated in a certified breast cancer center.
A quarter is an enormously high rate. How many patients in Germany are treated in such centers?
Unfortunately, only about half of all cancer patients in Germany receive their care in certified centers of this kind – more for breast cancer and less for lung cancer. That is scandalous. The others are often admitted to hospitals that have the capacity but do not offer the same specialization and experience. And that's not just the case for cancer; we have the same situation for strokes.
Prof. Dr. med. Reinhard Busse
Reinhard Busse is a professor of Health Care Management at the Technical University of Berlin and a faculty member at the Charité – Universitätsmedizin Berlin. He is co-director of the European Observatory on Health Systems and Policies and heads the Berlin Centre for Health Economics Research (BerlinHECOR). His research interests include health system analysis, particularly in European comparison, as well as health services research and the integration of outpatient and inpatient care. He is also a member of the government commission for modern and demand-oriented hospital care.
What influence do the financing systems have here?
A decisive one. Our hospital financing works in such a way that hospitals are paid for occupied beds. This means that hospitals have a strong financial incentive to admit as many inpatients as possible. Hospitals that are not working at full capacity are at a financial disadvantage. If the system were to move more in the direction of cross-sector, integrated care, patients could receive targeted outpatient and inpatient care in specialized centers.
How do you assess the hospital reform in this regard?
In my opinion, the planned hospital reform is a step in the right direction, but the steps are still too small to solve the systemic problems. The reform is intended to make care more specialized, thus ensuring that cases that are more complex are treated in hospitals equipped for them, while other facilities concentrate on less complex cases. This is a step in the direction of integrated care and a more efficient use of resources, but the incentive for inpatient treatment remains as long as inpatient capacities are not actually reduced. The conversion of hospitals into outpatient-inpatient care centers, as provided for in the law, is also essential.
What role can digitalization play in an effective healthcare system?
A crucial one. Quick access to reliable data can help with deciding what the ideal care for patients is – and where it can take place. Digitalization can make the system more efficient and transparent. However, to do that, a solid database must be created. In Germany, we simply do not systematically collect many important data – such as the survival rate after a heart attack. International statistics are available, but in Germany we do not know how many are still alive 30 days after a heart attack.
“International statistics are available, but in Germany we do not know how many are still alive 30 days after a heart attack.”
Good digitization would improve the data situation and make it transparent, so that we could better compare and control care outcomes. However, digitization also requires that the players in the system are willing to embrace greater transparency. Many are critical of this because it would automatically stimulate discussion about the efficiency and benefits of the services provided.
Why do you think there is so much resistance to greater transparency and digitization in healthcare?
Transparency could call into question some structures that have existed unnoticed until now. Disclosure of health data means allowing yourself to be measured and compared – and not everyone sees that as an advantage. There are areas in the system that are inefficient, and disclosure of this data could lead to discussions about the meaningfulness of certain services or structures. Good digitization would enable such discussions, but for that, there needs to be a willingness to change. This change is urgently needed. Patients would benefit enormously from it. Specifically, this means living longer and better.
At the fourth Stuttgart Health Talk in autumn 2024, Berlin health economist Reinhard Busse discussed his findings with Robert Bosch Stiftung CEO Dr. Bernhard Straub (left), Baden-Württemberg's Minister of Health Manfred Lucha (center right) and Prof. Dr. Mark Dominik Alscher, CEO of the Bosch Health Campus (right).
