A new study has highlighted well-documented problems in the German health care system - doctors have a huge financial incentive to offer unnecessary treatments, and hospitals remain under intense financial pressure.
German hospitals and doctors are potentially endangering their patients' health by talking them into expensive treatments and unnecessary operations, according to a new study by the SOCIUM research center at Bremen University.
The study, based on around 60 interviews with doctors and hospital directors across the country, found that Germany was struggling to cope with the more complex illnesses that come with an aging population.
The researchers found that while the number of patients is increasing in the country, the length of hospital stays are shortening, as doctors have a financial incentive to admit more people to hospital, and staff are under economic pressure to then discharge them quickly.
"The system functions at the expense of the patients and medicine," said study author Karl-Heinz Wehkamp. "We could have interviewed many more doctors. Most of them had a desire to talk about it and wake up the public and the politicians." Wehkamp is a doctor himself, while co-author Heinz Naegler is an economics and law professor who managed hospitals in Berlin and Vienna.
Not an insurance problem
Dr Johannes Schenkel, medical director of Germany's independent patients' advice center UPD, said that the report's conclusions were not new, but the vehemence of some of the doctors' interviews had surprised him. "That always came under the cover of professional discretion before," he said.
Ines Verspohl, health care consultant at Germany's social care association (VdK), suggested this was a basic problem of any profit-based health care system. "It's a fundamental problem, and it's not down to the health insurers, it's down to the private service providers, which are profit-oriented," she said.
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Previous studies have also shown that German doctors often tend to carry out unnecessary x-rays for back pain, pre-operative examinations like ECGs, or put in unnecessary heart or bladder catheters.
But is this over-treatment endangering patients' health? "We don't really know exactly how much damage this causes altogether," said Schenkel. "There is potential damage to every unnecessary operation and every unnecessary diagnostic treatment – a simple bladder catheter can of course always lead to an infection, in worst cases to a toxic sepsis in the body. A heart catheter can always bring problems at the puncture site - it can cause a hematoma, an infection, internal bleeding, or in the worst cases a sepsis that can be deadly."
As Verspohl pointed out, Germany has attempted to reform its health care system in the past few years, but that didn't alter the profit trend. "The basic problem is that it's not as if there are right and wrong operations: there is a very big gray zone, and the doctor has to decide: am I going to operate, or should I wait? If someone has some wear to their hip – should you operate or should you do a bit more physiotherapy and wait?" she said. "That isn't always an easy decision, so the doctor often chooses the economically better option."
In an emailed statement, a Health Ministry spokeswoman argued the government had taken a number of steps to limit over-treatment in the past legislative period. "These include regulations around cutting out so-called head doctor bonuses that are tied to mass treatments," she said.
The ministry added that doctors have a professional obligation not to abuse the trust of their patients, and that patients facing surgery have a legal right to seek a second opinion from another specialist doctor or hospital – though that right, as both Verspohl and Schenkel said, is rarely used. "We always advise patients facing surgery to ask doctors to explain exactly why they need it and to seek a second opinion," said Schenkel.
A home-made problem
But the problem also appears to be down to creeping privatization. "It's a problem that has been made by our health care policy," said Schenkel. "This economization of hospitals – that's a home-made problem. It was completely predictable and clearly criticized when it was first introduced at the end of the 90s."
One reform, which changed the way hospitals were paid, has had an accelerating effect on care – rather than taking money for every day of a hospital stay, hospitals now get paid for a specific treatment. "[The old] system wasn't necessarily better, because it meant patients were kept in hospital longer than they needed to be, now we have the opposite problem," said Verspohl. "That patients are discharged even though they're not really healthy yet."
"Germany has too many hospitals," said Verspohl. "And they're trying to close hospitals, but without a real political plan – without a plan saying: right, we're going to close this hospital and keep this one open. Instead, some hospitals are just going bankrupt. And of course that's not good for the patients, because not the best hospital survives - just the economically best."