Competition between hospitals and free standing units (FSU)
Since 1992 all hospitals in Germany are allowed and encouraged by government to perform surgery on an ambulatory basis. At the same time doctor´s offices used for ambulatory surgery had to meet certain requirements, e.g. a separate and specially equipped operating room. These specialized doctor´s offices are FSU and are called day clinics or praxis clinics in Germany.
After more than 10 years of competition between hospitals and FSU the distribution of ambulatory surgical procedures remains:
There are several reasons why ambulatory surgery is mainly performed in day clinics:
Reimbursement
The fees for ambulatory surgical procedures are the same in hospitals and in FSU; they are fixed by a semi-governmental agency. But theses fees are not cost covering, neither in hospitals nor in FSU. They are approximately 1/5 the prices hospitals get for inpatient treatment of the same surgical procedure.
Therefore there are no financial incentives for hospitals to move into ambulatory surgery.
Costs
For the same type of procedure costs are higher in hospitals than in FSU [3]:
Total costs for e.g. laparoscopic tubal ligation (pre-, intra-, postoperative therapy incl. anaesthesia etc.)
| hospital inpatient | 1 823,- EUR | 100% | 46% higher than in FSU |
| hospital outpatient | 1 111,- EUR | 61% | 11% higher than in FSU |
| FSU | 993,- EUR | 54% |
Despite these economic advantages government did not change politics with respect to inpatient treatment.
Emancipated physician
In FSU the surgeon is “emancipated” from any hospital system and can advice patients in a free way. Some characteristics of self-employed physicians are:
Emancipated patient
The modern, emancipated patient
For many women these are strong arguments for getting surgical treatment in a FSU.
Transparent quality control
The results of surgery should be controlled not only by other physicians but also and predominantly by patients.
The quality control system of the German Association for Ambulatory Surgery (BAO) uses such a questionnaire.
The results of 10 years' experience with patient questionnaires and institutional reports confirm [1,2]:
1. Complication rates (1992-2001) monitored by patients and physicians were very low:
a. overall complication rate 0,65%
b. infection rate 0,36%
c. wound infection rate 0,11%
2. Yearly institutional reports including cases with complications are helpful for quality management in the FSU as well as for information of physicians and patients.
3. Reports should be open to public (homepage, newsletter etc.).
Progress in medicine
During the years of competition between hospitals and FSU it became clear that there are 3 main factors essential for success in surgery:
1. Quality of surgery measured by complication rates
2. Total costs of procedure
3. Patient satisfaction with pre- and postoperative care
Progress in medicine is best achieved if the patient´s problem is relieved by a fast and safe surgical procedure.
Country-wide medical services
FSU are spread all over the country, also in rural areas.
In Germany there exists a long tradition of FSU for specialized surgery of members of the Worker´s Medical Cooperative For Surgery (Berufsgenossenschaft BG). This is a governmental insurance agency for all working people. The BG insures accidents in connection with working and is represented in hospitals, but mostly in FSU. These BG-FSU are run by one or more certified surgeons.
FSU - Centers of competence
FSU are now developing into interdisciplinary centers of competence.
One example are breast clinics (“Brust-Ambulanz”, www.brust-ambulanz.info). This is a network of FSU which specializes in the treatment of breast cancer and usually has offices (FSU) for surgery, radiology, oncology, pathology, radiotherapy, physiotherapy, psychological councelling, a documentation center (Tumorzentrum), affiliated (university) hospitals, and women´s self-aid groups.
Other centers of competence are emerging, e.g. for uro-gynecology and infertility.
Legal aspects
German doctors in offices (FSU) are self-employed. Actually they have more rights than the government in our social state wants to concede:
Unilateral disadvantages of free standing units
With regard to ambulatory surgery FSU obviously were more successful than hospitals in this competition between free enterprises and a governmental health system.
What the representatives of the ruling system often regard as a disadvantage:
But how heavy weigh these losses in comparison to the benefits of a patient-oriented medical treatment of high quality at low costs?
The future of ambulatory surgery lies in free standing units run by experienced surgeons with quality control by patients.
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References
[1] Brökelmann,J, P. Bung: Komplikationsraten in der ambulanten operativen Gynäkologie. Frauenarzt 2002;43:1046-1051
[2] Brökelmann, J: Leistungsberichte einer gynäkologischen Tagesklinik. Ambulant operieren 2003;1:44-46
[3] Eichhorn S., Ewersmeyer H. Evaluierung endoskopischer Operationsverfahren im Krankenhaus und in der Praxis aus Sicht der Medizin, des Patienten und der Ökonomie. Thieme Verlag Stuttgart, New York 1999
Address: Prof. Dr. Jost Brökelmann, Friedensplatz 9, 53111 Bonn, Germany
Email: gyn-praxisklinik-bonn@t-online.de
Web: www.gyn-praxisklinik-bonn.de, www.arzt-in-europa.de