Hospital funding

As hospital financing the provision of funds for setting up and operation is of hospitals designated. In Germany, patient services are billed according to the rules of the Social Security Code . In addition, special legal regulations apply to the investments in accordance with the Hospital Financing Act and corresponding state laws.

background

hospital

According to § 107 Abs. 1 SGB V , hospitals are facilities that

are used for hospital treatment or obstetrics,
are under constant medical supervision, have sufficient diagnostic and therapeutic options appropriate to their care mandate and work according to scientifically recognized methods,
with the help of medical, nursing, functional and medical-technical personnel available at all times, are equipped to recognize, cure, prevent illnesses in patients, to alleviate illness symptoms or to provide obstetrics, primarily through medical and nursing assistance, and in which
the patients can be accommodated and fed.

Contrary to the Anglicist diction in marketing, hospitals are not production facilities but service facilities under existing contract law.

Former term of hospitals

According to ordinance PR 7/54 on nursing care rates for hospitals of August 31, 1954, Section 1, Paragraph 1, No. 1 and 2 fall under the concept of hospitals: a) Institutions in which sick people are accommodated and cared for and in which by (permanent ) medical assistance is sought to diagnose, cure or alleviate illnesses, ailments or physical injuries and b) maternity institutions.

General development

The first modern hospitals appeared in the 18th century . In 1710 the Charité was founded as a plague hospital, but not until 1727 as a "Lazareth and Hospital" for the state Collegium medico-chirurgicum founded in 1724 . In 1717, J. Juncker in Halle an der Saale used the hospital of the Francke Foundations for clinical teaching (Collegium clinicum Halense). With the opening of the General Hospital in Vienna with around 2,000 beds in 1784, Emperor Joseph II set standards for large hospitals in Central Europe. From 1836, based on the idea of the Protestant theologian Theodor Fliedner , civilly dressed deaconesses who attended a nursing school with modern teaching methods worked in hospitals. In addition to scientific and medical upheavals, experience in wars also brought about particular innovations in the nursing areas of hospitals. A large number of hospitals emerged in the 19th century, which were only seen as social institutions in order to alleviate the suffering of the population through care and support. The number of doctors was still limited and increased with medical advances and new techniques.

In Germany, hospital care was mainly carried out by churches and charitable institutions as providers and thus systematically ensured care. For example, the Friederikenstift opened in Hanover in 1841 or the Elisabeth Hospital in Essen, which opened in 1844 . It was not until later that cities and municipalities also took over hospital care as municipal providers. Examples: Klinikum Ernst von Bergmann Potsdam , Municipal Hospital Lüneburg .

See also: history of the hospital

Sponsors of the hospitals 2012, 2010, 1991 and 1966 *
heading	public	Public swimming profit	private- economic	total
Hospitals 2012	601	719	697	2.017
Hospitals 2010	630	755	679	2,064
Hospitals 1991	1.109	944	358	2.411
Hospitals 1966	1,366	1,291	978	3,635
Beds 2012	240.275	171.170	90.044	501,489
Beds 2010	244.254	173.457	85.038	502.749
Beds 1991	297.731	200,859	48.710	547,300
Beds 1966	352,603	233,651	54,118	640.372

* Data from 1966 only West Germany including West Berlin.

For both types of sponsors, today classified as non-profit and public , the intention to make a profit was not considered a special characteristic for the operation of a hospital. The top priority was the fulfillment of the social task. In the course of the demands of the modern performance society, the expectation of the patients for high-quality services of the hospital staff (doctors, nursing, treatment options), the supply and equipment (medical devices, drugs, implants, room equipment, food supply) increased. Fluctuating patient numbers and the course of illness are largely offset by rising personnel and operating costs.

In recent years, the share of municipal hospital operations has decreased. Some of the institutions, which are mostly run by cities and municipalities, were no longer able to partially offset the costs through the budget. Several private clinic operators, including larger clinic groups , took over some of the hospitals; in turn, numerous other locations had to be closed. The number of hospitals in Germany fell from 2,411 facilities in 1991 to 2,045 hospitals in 2011. At the same time, the number of cases rose from 14.5 million to 18.3 million and the average length of stay of a patient was reduced by 14 Days in 1991 to 7.7 days in 2011. In addition, some of the medical and operational services were also shifted to the outpatient area.

According to annual overviews by the German Hospital Association (DKG), the typical personnel costs of modern hospitals for a service in the health sector are at a share of at least 50% to mostly 66%. The amount varies depending on the coverage of personnel deployment by external service providers, since personnel outsourcing and the use of fee-based doctors (loan doctors) are counted as material costs. The primary goal of today's hospital operations is cost-covering service provision, but in many hospitals the intention to make a profit also plays a major role.

Since 1972, hospital financing in Germany has been based on the principle of dual financing and the Hospital Financing Act (KHG) for the majority of facilities . Hospitals that are not on the state's hospital plan, e.g. B. Contract hospitals in accordance with Section 108 No. 3 SGB V, are only financed through the care rates according to the Federal Care Rate Ordinance (BPflV), which means one- tier hospital financing . For psychiatric and psychosomatic hospitals, a performance-based and flat-rate remuneration system will be mandatory from 2015. The basis for this is the Psychiatry Remuneration Act (PsychEntgG) passed in 2012.

Health insurance

With the beginning of financial security for workers through high industrialization with the introduction of social security legislation in the German Empire, especially the Health Insurance Act of 1883 for the introduction of statutory health insurance (GKV) - initially for workers - and the Accident Insurance Act of 1884, state control began and Hospital development. The benefits granted to the insured included medical treatment , medicines and aids and hospital treatment. Initially, the employer contributed 1/3 and the employee 2/3. An assessment ceiling was set for both payments .

In order to secure the premium income today, people and organizations are mainly obliged to take out insurance . The benefit requirement for one year is almost entirely covered by the premium income for the same year, i. H. The accumulated capital essentially only serves as a short-term fluctuation reserve ( sustainability reserve , generation contract ). The benefits are primarily provided as benefits in kind that are the same for all insured persons (principle of solidarity ) or as contribution-based cash benefits (e.g. pensions, sickness benefits ). It is financed for the most part from contributions , in some branches also from tax revenues. The contributions are based on the gross wages and salaries up to the amount of the assessment ceiling and are (with exceptions) "equal" , that is, half of the employer (as ancillary wage costs ) and half of the employee .

This insurance system goes back to Otto von Bismarck . The hospitals are subject as part of the German health the institutional framework of the Fifth Book of the Social Code (SGB V) to the statutory health insurance (SHI):

Solidarity principle of the statutory health insurance (§ 1 SGB V),
Contribution financing by employers and members of the health insurances (§ 3 SGB V),
Postulate of contribution rate stability (§ 71 SGB V).

According to Section 70 of the Book V of the Social Code, hospital treatment must “guarantee needs-based and uniform care for the insured in accordance with the generally recognized state of medical knowledge. The care of the insured must be sufficient and appropriate, must not exceed what is necessary and must be provided in the professionally required quality and economically ”. The following areas can be distinguished in hospital services:

Full and part inpatient (Section 39),
Pre- and post-inpatient (Section 115a),
Outpatient (§§ 115b, 116a ff.).

See also: Types of Treatment

Overview of the forms of hospital financing

Hospital financing provides the investment capital and working capital. In principle, there are the following forms of financing in hospital financing:

Free hospital financing (in Germany until 1936)

Monistic hospital financing through a single financial stream : Monistic (in Germany from 1936 to 1972)

Dual hospital financing through two financing streams (in Germany formally 1973 to today)

Trial hospital financing through three financing streams (e.g. by the state, health insurance companies and carriers)

History of Hospital Funding

1945 to 1953

In the Federal Republic of Germany, the monistic hospital financing introduced in 1936 was retained. As a result of the Second World War , up to a third of the hospital infrastructure, especially in the big cities, was destroyed. In addition to the plan beds, numerous “emergency beds” had to be set up. There was also a lack of facilities and modern medical equipment and consumables. The porters often had to finance the investments with their own assets. Due to the price law of April 1948 on price formation and price monitoring, public sector contracts had to be based on the guiding principles for price determination on the basis of prime costs. In principle, market prices were to be agreed. If this was not possible, for example due to a lack of suppliers, a cost reimbursement price was permitted in exceptional cases. Hospital owners as well as cities and municipalities demanded from politicians a change in hospital policy and the assumption of running costs as well as investment costs by adjusting the nursing rates. The federal government and the health insurance companies rejected this on the grounds that sufficient provision of hospital facilities was the responsibility of the state and thus also of the municipalities and states. The users and the payers should in turn finance the ongoing operating costs.

1954 to 1971

Ordinance PR No. 7/54 on hospital care rates (Federal Care Rate Ordinance) of August 31, 1954 (Federal Gazette No. 173 of September 9, 1954) and the relevant circular were based on the Price Act . The care rate ordinance provided for only a small share of the health insurance companies in the costs of the hospitals. They only received the costs for repairing war damage and for necessary modernization measures. The legislature wanted to prevent the economy from being burdened by increases in health insurance contributions. As a result, the operating subsidies from the municipalities to the hospitals were offset against the cost of care eligible for care, with the result that the municipalities had to continue to pay subsidies. In addition, the law allowed the health insurance companies to refuse an increase in nursing care rates within the framework of the applicable provisions if the hospitals did not meet the obligation to provide economic efficiency. The Federal Nursing Rate Ordinance did not even replace the prime costs, although the public sector subsidized the construction of new hospitals and supported the owners with operating subsidies. The number of underfunded and loss-making hospitals rose rapidly and the situation was increasingly discussed in public and political discussions. The hospitals demanded support from the legislature and an adjustment of the nursing rates to a cost-covering level.

An investigation by the Federal Ministry of Economics under Ludwig Erhard in cooperation with the pricing offices of the federal states on the basis of a questionnaire in 1957/58 showed that in 1957 costs in the sense of VO PR 7/54 (restricted cost principle) were estimated to be Amount of around 480 million DM were uncovered. The conventionally paid operating subsidies of around DM 200 million annually were deducted from this amount, leaving a deficit of around DM 280 million compared to cost.

In order to stabilize the financial situation of the hospitals, the Federal Minister of Health Elisabeth Schwarzhaupt had initially favored the establishment of a permanent financing company in July / August 1966 with the participation of the social security agencies and, if necessary, the federal government and the states. Due to the additional burdens on the statutory health insurance, the Federal Ministry of Labor under Hans Katzer rejected a change to the federal care rate regulation. In a meeting of the state secretaries chaired by Ludger Westrick , Federal Minister for Special Tasks, it was agreed on August 2, 1966 not to change the nursing care rate ordinance and instead to make additional funds available to hospitals by shortening the depreciation periods for buildings.

A nationwide investigation into the financial situation of the hospitals was also agreed. The Hospital Enquete report on the financial assessment of the German hospital system, which was presented to the German Bundestag in 1969, revealed a predominantly deficit situation with annual losses of around 800 to 900 million DM (409 to 460 million euros). According to the report, "in the interests of a long-term and permanent reorganization, the aim is to ensure that public financial aid for the construction of hospitals is also made binding in terms of the amount". From then on, the political majorities demanded support from the hospitals and saw the provision of these health facilities as a public task . The health insurances and the insured should not compensate the financial problems of the hospitals by increasing the nursing care rates.

The constitutional competences of the federal government were limited and no responsibility for financing was given. According to Article 74, Paragraph 1, No. 11 of the Basic Law, the maintenance rates could only be regulated according to the law on prices. With the 22nd amendment to the Basic Law of May 29, 1969 ( Federal Law Gazette I p. 363 ), Paragraph 1 No. 19a was added to Article 74, which gives the Federation the competence of the competing legislation on the economic security of hospitals and the regulation who transferred care rates.

In the government declaration by Federal Chancellor Willy Brandt on October 29, 1969, it was announced that a law would be introduced to economically secure a needs-based system of efficient hospitals. A commission of experts is to contribute to the further development of health insurance, to take stock of the situation and to draw up proposals for modern legislation.

1972 to 1989

With the law on the economic security of hospitals and the regulation of hospital care rates (Hospital Financing Act) (KHG) of June 29, 1972, economic security should be supported to the extent that efficient and needs-based health care is achieved in the Federal Republic of Germany. In order not to burden the cost of profitability through increases in social security contributions and thus directly burden the insured, dual financing was introduced according to § 4 KHG . With the introduction of the KHG, the decision of the state to subsidize investment costs rests with the federal states, which only take into account needs-based hospitals and investment projects. The federal states also introduced hospital planning .

In accordance with Section 1 of the KHG, the aim of hospital financing is in principle to ensure that hospitals are financially secure to provide needs-based care for the population, and to contribute to socially acceptable care rates with high-performance and self-reliant hospitals (self-cost coverage principle). In particular, the economic security of non-profit and private hospitals must be guaranteed in accordance with state law. The granting of funding under this Act may not be linked to conditions that impair the independence of hospitals beyond the requirements of hospital planning and economic management. A characteristic of the dual financing is the separation of the costs into investment costs, which are raised by the federal states, and costs eligible for care, which are to be borne by the insured or their health insurance.

Until 1974, the maintenance rates were still based on the old price law. On April 25, 1973 the first Federal Care Rate Ordinance (BPflV) was passed, which came into force on January 1, 1974. Each hospital charged individual general care rates without differentiating between departments. Section 17 (1) of the Federal Care Rate Ordinance provided for profit or loss compensation for the past care rate period ( cost recovery principle ) (cost recovery principle ). In the implementation, however, there was no guarantee for the hospital that it would actually get its own costs back in full, since only the necessary and economic cost factors were taken into account. Hospital costs continued to rise as a result of steadily growing medical advances, an increase in the number of cases and rising prices even after the introduction of the KHG and the BPflV. The expenditures of the health insurances for the hospital care rose from 1970 of 7.5 billion DM to 17.5 billion DM in the year 1975. In the course of the worsened economic framework conditions and also the situation of the statutory health insurance, the legislature began with a cost-containment policy in the health system.

With the Hospital Cost Reduction Act (KHKG) of December 22, 1981 ( Federal Law Gazette I p. 1568 ), the instruments for demand planning should be improved and a change in investment funding. The hospitals were divided into four levels of care in the hospital plans and the amount of the lump-sum funding (henceforth up to the amount of DM 50,000 net) also related to the level division.

The federal states demanded more competence and design options. With the Hospital Reorganization Act (KHNG) of December 20, 1984 ( Federal Law Gazette I p. 1716 ), federal financial aid for the investment sector was abolished. Financing became the sole responsibility of the federal states. The care rates set by the federal government were no longer fixed by the state, but the now prospective care rate was agreed individually between the hospital and the health insurance companies. In addition, the financing was increasingly geared towards the costs calculated in advance. In the event of a conflict, the care rates were set by an arbitration board. Final approval remained with the federal states. Emphasis on the principle of the diversity of providers and the legal entitlement of hospitals to funding in accordance with Section 8 (1) of the KHG was also introduced.

On August 21, 1985, a new Federal Care Rate Ordinance (BPflV) ( Federal Law Gazette I p. 1666 ) was issued, which came into force on January 1, 1986. The Hospital Financing Act (KHG) was revised on December 23, 1985 ( Federal Law Gazette 1986 I p. 33 ). For the first time, a flexible budget was introduced to secure fixed costs, with daily care rates as down payments and the admission of profits and losses. An intention to make a profit , also through rationalization measures , was allowed. With revenues deviations from the preliminary costing the budget could be adjusted or a revenue compensation be decided in a care rate negotiations. According to Section 4 (1) of the Federal Care Rate Ordinance of 1986, variable costs were assumed to be 25% and fixed costs to be 75%.

1990 to 2001

With the law to safeguard and improve the structure of statutory health insurance (Health Structure Act ) (GStrukG, GSG) of December 21, 1992 ( Federal Law Gazette I, p. 2266 ), there was a comprehensive health reform with drastic changes with rising costs in the hospital system and for the first time after the reunification of Germany to stabilize health insurance contributions. The most important changes were the budgeting of service expenditures and administrative costs , introduction of a drug and medicinal product budget, increasing co-payments by insured persons, control of the number of doctors through requirement planning , nursing staff regulation (PPR), introduction of free choice of health insurance companies , a risk structure compensation between the individual health insurance companies , a planned one Introduction of a positive list for pharmaceuticals , funding of outpatient operations (§ 115 b SGB V) and the introduction of a new remuneration system for hospitals . With the GSG there was a cap on the hospital budget from 1993 to 1995, the increase of which was basically only based on the development of basic wages . The budget increase was not allowed to rise higher than the contributory income of those insured by the health insurance companies.

With the third revision of the Federal Care Rate Ordinance (BPflV) of September 26, 1994, which came into force on January 1, 1995, the care rates were no longer based on the cost recovery principle that was valid until December 31, 1992, but instead flat-rate per case and special remuneration were new Forms of payment introduced. Flat rate per case for certain treatment cases, special fees for certain operations. As well as an individual hospital budget, which was settled with the help of department and basic nursing rates (fees for medical and nursing activities). With the Stabilization Act of April 29, 1996 ( Federal Law Gazette I p. 654 ) and other laws, the budget cap was continued.

With the law on the reform of statutory health insurance from 2000 ( GKV-Gesundheitsreformgesetz 2000 ) of December 22, 1999 ( Federal Law Gazette I p. 2626 ), the existing cap on the hospital budget was continued and the compensation of the collective wage increases above the rate of change continued limited. A flat-rate performance-based remuneration system for hospital treatment is to be introduced. So far, psychiatry and psychosomatics as well as a few, very small and highly specialized hospital departments (pediatric rheumatology, department for tropical diseases) have been excluded from this remuneration system.

2002 to 2015

The diagnosis-related flat-rate fees (DRG) were introduced through the case flat rate law (FPG) of April 23, 2002 ( Federal Law Gazette I p. 1412 ) and the regulation on the case flat rate system for hospitals (KFPV) of September 2002 by the Federal Ministry of Health . This was voluntarily applicable from 2003 and mandatory from 2004. With the introduction of the DRG system , the law on fees for full and part-time inpatient hospital services ( Hospital Remuneration Act , KHEntgG) of April 23, 2002 came into force and, according to Section 17b of the KHG, a consistent, performance-oriented and flat-rate remuneration system was introduced determined according to the "top-down principle". The somatic hospital services are essentially remunerated via flat-rate fees ( DRGs ). Each DRG is assigned a so-called cost weight. They depict the average resource expenditure based on the severity of the case. Other revenue components ( additional fees, other fees, surcharges and deductions, same-day fees above the limit length of stay ) are anchored in law. In addition, the legislature has opted for a fixed price system that will be implemented at the end of the transition period (budget-neutral and convergence phase) through a nationwide base rate for all hospitals. Multiplying these two components by the number of cases results in the hospital's DRG revenue budget. The DRG revenue budget is supplemented by the other revenue components and thus results in the hospital's overall budget.

In relation to the hospital budget, for compensatory reasons, surplus and shortfall revenue adjustments are permitted, that is, the budget is made more flexible. This increases the risk of loss for unprofitable hospitals with expensive cost structures. At the same time, however, the profitable hospitals can make more profit. The legislature has made different regulations for the scope of application. For example, the DRG case groups and relative weights are determined nationwide. The base rate is set at the state level, while the other fees are negotiated at the hospital level.

With the law amending the regulations for the diagnosis-oriented flat rate system for hospitals ((1.) Flat rate change law ) (FPÄndG) of July 17, 2003 ( Federal Law Gazette I p. 1461 ), the first corrections had to be made. For this purpose, in particular, the options for a targeted lifting of decision-making blocks for the self- government partners were improved by means of a ministerial ordinance of the Federal Ministry of Health. Additional options for action are opened up to enable appropriate remuneration regulations for the services of individual specialist areas (e.g. epilepsy, geriatrics, pediatrics, treatment of severely disabled people) and special facilities (special clinics).

The law on the modernization of statutory health insurance ( GKV-Modernisierungsgesetz ) (GMG) of November 14, 2003 ( Federal Law Gazette I p. 2190 ) came into force on January 1, 2004 after a cross-party compromise and should reduce the contributions to the statutory health insurance and thus the Permanently reduce non-wage labor costs. For this purpose, in addition to far-reaching regulations, the increased possibility of carrying out outpatient treatments was introduced. This led to the establishment of medical care centers (MVZ) and an expansion of the outpatient surgical centers in hospitals.

With the second law amending the regulations for the diagnosis-oriented flat rate system for hospitals and amending other regulations (second case flat rate amendment law; 2nd FPÄndG) of December 15, 2004 ( Federal Law Gazette I p. 3429 ), extensive corrections to the G-DRG System made. The adjustment phase (convergence) of the previous hospital-specific prices to the national average was extended and revised. In addition, the law led to the amendment of Section 134 SGB V with regard to the remuneration of midwifery services.

Fees for new examination and treatment methods (NUB) were introduced as early as 2005, which cannot be properly mapped with existing fees.

Since 2005, a uniform base rate has been agreed for each federal state (LBFW). The individual hospital then only agrees the service planning with the payers. The base rate of the hospital has been gradually adjusted in the years 2005 to 2009 to the state base value (convergence phase). Since 2010, only the state base rate has been in effect and thus a uniform base price for the DRG services in the respective federal state. However, a uniform price in Germany has not yet been achieved.

With the law on the regulatory framework for hospital financing ( Hospital Financing Reform Act; KHRG) of March 17, 2009 ( Federal Law Gazette I p. 534 ), the flat-rate funding for facilities listed in the hospital plan was supplemented with a performance-based investment flat-rate. This has been implemented in the federal states' hospital laws since 2011/2012. Since then, the flat-rate funding has been made up of a basic flat rate and a performance flat rate. In addition, there was a new calculation basis for the revenue budget according to § 4 KHEntgG. Due to the development of the case volume and the corresponding increases in expenses for hospital services, additional service discounts (MLA) were first introduced as a cost-cutting instrument in 2009. The discounts for the hospital services provided were negotiated at the local level between the hospital and the payers (including the health insurance companies). With the GKV Financing Act, discounts were again established from 2011 to control additional services. In 2016, the advance payment was around 25 percent and was valid for three years.

A survey carried out on behalf of the Working Group on Hospitals of the Working Group of the Supreme State Health Authorities (AOLG) showed that the federal states made a total of around 2.82 billion euros available for investment funding in accordance with Section 9 KHG (2009: 2.861 billion euros). This did not include the investment funds of the university clinics, the investment funds of the contract hospitals, the own funds of the planned hospitals and the funds for the remaining financing of measures that were not yet fully financed. The total amount is made up of the individual funding according to § 9 Paragraph 1 and 2 KHG amounting to around 1.65 billion euros and the lump sum funding according to § 9 Paragraph 3 KHG amounting to around 1.17 billion euros. According to the KHG, the volume of investment subsidies in the federal states fell from 2000 to 2010, adjusted for price, by around 28 percent.

With the agreement signed on December 14, 2012 on a uniform base rate and a uniform base rate corridor in accordance with Section 10 (9) of the KHEntgG, the contracting parties at federal level (GKV-Spitzenverband, Association of Private Health Insurance and the German Hospital Association) agreed on a uniform federal base rate for 2013 (BBFW) based on the calculation of the Institute for the Hospital Remuneration System (InEK) and only allowed differences within the framework of clearly defined corridor boundaries. The average base case value in Germany in 2012 was EUR 3,068.37. With the corridor limits, an adjustment of the base rate in 2016 to a maximum of EUR 3,394.77 or a lower limit of 3,270.48 is planned. The average value in 2016 was 3,311.98 euros.

On January 1, 2015, the Statutory Health Insurance Financial Structure and Quality Further Development Act (GKV-FQWG) came into force. The GKV-FQWG reduced the general contribution rate for statutory health insurance to 14.6 percent (previously 15.5 percent). Employees and employers each pay half of the contribution rate, i.e. 7.3 percent. This means that the share of 0.9 percent that was previously only to be paid by GKV members is no longer applicable, but the statutory health insurances can levy income-dependent additional contributions from their insured persons as part of their contribution autonomy. Article 1 No. 7 of the GKV-FQWG defines that the Joint Federal Committee (G-BA ) founds a professionally independent, scientific institute for quality assurance and transparency in health care (IQTiG). To this end, the G-BA is establishing a foundation under private law. The quality institute works both on quality assurance measures and on presenting the quality of care in the healthcare system. In addition, the introductory phase of the flat-rate remuneration system for psychiatric and psychosomatic hospitals and specialist departments (PEPP) was extended by two years.

On July 23, 2015, the Statutory Health Insurance Supply Strengthening Act (GKV-VSG) came into force. It led to a statutory second opinion procedure, to the further development of discharge management , the obligation to cooperate between the Association of Statutory Health Insurance Physicians (KV) with hospitals in outpatient emergency care, the evaluation of new examination and treatment methods (NUB) with high-risk medical products, and the facilitation of the approval of medical products Care centers (MVZ) as well as the introduction of an innovation fund with 300 million euros annually to promote integrated care and health care research in Germany.

As of 2016

The Hospital Structure Act (KHSG) was passed on December 10, 2015 ( Federal Law Gazette I p. 2229 ). Its changes will mainly take effect from January 1, 2016. It makes the financing of hospitals largely dependent on their quality. "Quality surcharges and discounts for extraordinarily good or inadequate quality give hospitals financial incentives to maintain and improve the quality of care." In addition, security surcharges and an extension of the hygiene promotion program. In addition, the additional service deductions (MLA) for hospital services provided in the amount of 25 percent were converted into a fixed cost degression deduction (FDA), which will be valid from 2017 and every increase in volume generally leads to a fixed cost degression , while maintaining the three-year validity . The amount of the FDA is determined by the self-government in the respective federal state. Transplants , multiple trauma and the care of severely burned people, premature babies and DRG services with a material cost share of over 66 percent are not affected by discounts . In the run-up, critics had demanded that clinics no longer pay for poor services. In addition, the quality controls of the Medical Service of Health Insurance (MDK) were introduced. Significant changes also concerned the raising of the lower corridor limit of the federal base rate (BBFW) and the adjustment of the upper corridor limit as well as the new method of determining the federal base rate (BFW) from 2021. In addition, the introduction of the hospital structure fund at the Federal Office of Administration in the amount of 500 million euros to support projects of Countries to improve structures in hospital care, including reducing overcapacity and converting hospitals into non-acute inpatient local care facilities such as health centers.

On June 1, 2017, with the law to update the regulations for blood and tissue preparations and to change other regulations, the establishment of the German Haemophilia Register (DHR) came into force, as well as improvements to discharge management and the introduction of the hospital doctor number (identical to the lifelong doctor number ( LANR)) for identification together with the permanent establishment number (BSNR) on prescriptions as well as the possibility of controls by the medical service of the health insurance (MDK) even without clues.

On January 1, 2019, the Nursing Staff Strengthening Act (PpSG) came into force with far-reaching changes in the DRG system for better staffing and better working conditions in nursing and geriatric care with adjustments to the Hospital Financing Act (KHG) and Hospital Remuneration Act (KHEntgG) and the inclusion of Section 137j SGB V . In it, the topics care budget, care revenue catalog, care staff quotient, care expenditure catalog, staff lower limits and care-sensitive areas are relevant factors.

Current hospital funding

Health insurance

The statutory health insurance funds finance the ongoing operating costs of the hospitals within the framework of the prescribed hospital remuneration.

Annual budget

Every hospital (possibly supported by the management of a hospital group ) negotiates an annual budget with the health insurance companies to reimburse full inpatient and partial inpatient hospital services. A certain amount of service is agreed for the following year in accordance with the supply contract for a hospital stipulated by the federal state.

The pricing is largely based on the evaluation ratios calculated by the Institute for the Hospital Remuneration System (InEK) for each diagnosis-related case group (DRG) in accordance with the G-DRG system introduced in Germany, which is revised or adapted annually. Specified in an annual agreement on the case flat rate system for hospitals (FPV) . From the number of diagnosis-related case groups (DRG), the case mix (CM) (case severity) is calculated as the sum of the evaluation ratios (cost weights; CW) of the individual hospital. The hospital's annual budget calculated for the following year is therefore calculated by multiplying the case mix with the state base rate (LBFW). The state base rate is set annually in the individual federal states and is different. A nationwide approximately uniform price for hospital services has not yet been achieved.

Revenue compensation

Since the negotiated annual budget relates to hospital services in advance, there are service deviations in the hospitals compared to the agreed service volume. Corresponding additional revenues (through additional services) but also lower revenues (through reduced services) should receive a so-called revenue compensation according to § 4 KHEntgG from the health insurance companies in the following year . As a rule, the additional services above the negotiated service volume are only remunerated at a reduced rate.

Psychiatric and psychosomatic hospitals

Compensation for full and part inpatient hospital services is still based on the Federal Care Rate Ordinance (BPflV) for psychiatric and psychosomatic hospitals. BPflV and KHEntG differ considerably in the form of the respective remuneration system. Houses for psychotherapeutic medicine or psychiatry are billed and remunerated with the help of daily care rates. A performance-based and flat-rate remuneration system will also be introduced from 2013. This is initially voluntary and will be mandatory from 2015. The basis is the Psychiatry Remuneration Act (PsychEntgG) passed in 2012. See also: Flat rate remuneration system for psychiatry and psychosomatics (PEPP).

Federal states

The federal states promote hospital investments (basic funding, lump-sum funding, etc.) in accordance with the guidelines on the procedure for granting funding in accordance with Section 9 (1) KHG, insofar as they are recorded in a hospital plan. There is a legal right to government funding for investments; for new buildings it is also necessary to be included in a state investment program. In Germany there are large differences in the scope of funding in the individual federal states. The funds are earmarked and are stipulated by the KHG and the state laws to the extent that they cover the investment costs that are eligible for funding and, in compliance with the supply mandate, necessary according to the principles of economy and economy.

Individual funding

With individual funding, the federal states finance long-term investments, which include new buildings or major renovation measures.

Lump-sum funding

The lump-sum funding is based on the number of beds according to the hospital plan and includes minor construction work and the replacement of short-term assets (in Lower Saxony according to NKHG, for example, with an average useful life of more than three and up to 15 years). The respective countries set a value limit. In Lower Saxony this is 150,000 euros.

With the law on the regulatory framework for hospital financing (Hospital Financing Reform Act - KHRG) of 2009, the lump-sum funding was supplemented by a performance-based investment lump sum. This has been implemented in the federal states' hospital laws since 2011/2012. Since then, the flat-rate funding has been made up of a basic flat rate and a performance flat rate.

Basic flat rate

The basic flat rate can also be increased if the reservation costs are particularly high and is also based on the number of planned beds and day-care places. Hospitals can also receive an allowance to fund necessary investments for training facilities (e.g. nursing schools) in accordance with Section 2 No. 1 a KHG.

Performance flat rate

The service flat rate is based on the number of inpatients treated (usually according to the diagnosis-related case groups ) and the depreciation of fixed assets in particularly cost-intensive service areas of a clinic.

Hospital costs

overview

Costs of hospitals in Germany in 2011 (Federal Statistical Office)
Year / state	Population Dec. 31, 2011	health houses	beds	Number of cases	Gross total costs in EUR	of which personnel costs in EUR	Share of personnel costs	including material costs in EUR	Share of material costs	Adjusted costs per case in EUR *
Baden-Württemberg	10,786,227	285	56,910	2,059,083	10,462,693,000	6,450,228,000	61.65%	3,696,022,000	35.33%	4,218
Bavaria	12,595,891	370	75,827	2,811,503	12,756,283,000	7,643,317,000	59.92%	4,780,687,000	40.08%	4,041
Berlin	3,501,872	79	19,905	771.418	3,873,529,000	2,137,817,000	55.19%	1,638,180,000	44.81%	4,276
Brandenburg	2,495,635	53	15.210	544,582	2,046,111,000	1,169,716,000	57.17%	838,347,000	42.83%	3,569
Bremen	661,301	14th	5.134	200.279	935,471,000	528,823,000	56.53%	375,888,000	43.47%	4,424
Hamburg	1,798,836	47	12,071	461.221	2,594,567,000	1,383,746,000	53.33%	1,210,821,000	46.67%	4,628
Hesse	6.092.126	174	35,941	1,299,328	5,867,105,000	3,345,084,000	57.01%	2,342,194,000	42.99%	4,060
Mecklenburg-Western Pomerania	1,634,734	39	10,375	410.150	1,661,860,000	962,588,000	57.92%	674,509,000	42.08%	3,575
Lower Saxony	7,913,502	197	42.204	1,615,879	7,391,018,000	4,413,907,000	59.72%	2,738,473,000	40.28%	3,890
North Rhine-Westphalia	17,841,956	401	121,556	4,286,435	19,513,513,000	11,665,002,000	59.78%	7,249,342,000	40.22%	3,876
Rhineland-Palatinate	3,999,117	95	25,375	890.729	3,815,467,000	2,408,637,000	63.13%	1,298,649,000	36.87%	3,807
Saarland	1,013,352	23	6,451	266,487	1,239,818,000	754,341,000	60.84%	442,742,000	39.16%	4.193
Saxony	4,137,051	80	26,467	986.173	3,904,149,000	2,220,194,000	56.87%	1,637,693,000	43.13%	3,694
Saxony-Anhalt	2,313,280	49	16,388	591.354	2,365,056,000	1,438,438,000	60.82%	896,358,000	39.18%	3,645
Schleswig-Holstein	2,837,641	94	15,990	580,808	2,706,199,000	1,561,176,000	57.69%	1,058,138,000	42.31%	3,993
Thuringia	2,221,222	45	16,193	568.731	2,282,955,000	1,402,903,000	61.45%	843,955,000	38.55%	3,630
Germany	81,843,743	2,045	502.029	18,342,989	83,415,795,000	49,485,917,000	59.32%	31,647,443,000	40.68%	3,960

* = Adjusted costs = gross costs minus non-inpatient costs, e.g. outpatient clinic, scientific research and teaching. Material costs also include expenses for the training fund, costs for training facilities and interest.

Personnel costs

Cost type	proportion of	Occupational groups (selection)
Nursing service	31.7%	Nursery Manager (Director of Nursing), Pflegewirt, nursing manager, nursing educator, case managers , specialist for the management of a functional unit (station management), maintenance / -mann , Fachgesundheits- and nurses (station service), health and nursing , health and pediatric nurses, health and care assistant / health and nursing assistants , professional health , Diakonie sister , Praxisanleiter , everyday companion , presence force hygiene specialist etc.
medical service	29.8%	Medical director , chief medical officers , chief consultant, senior physicians , medical specialists , medical assistants , physician assistant , pharmacist , hospital epidemiologist , (without locum doctors )
Medical-technical service	13.4%	Pharmacists , chemists , dieticians , clinical social services ( social pedagogues , social workers ), masseurs and medical pool attendants , medical assistants (medical assistants, typists in the medical and medical-technical field) , medical-technical assistants , medical-technical laboratory assistants, speech therapists , orthoptists , pharmaceutical-technical Assistants , physiotherapists , psychologists , medical documentaries, etc.
Functional service	9.8%	Anesthesia technical assistant , surgical technologist , occupational therapist , nurse anesthetist , specialist nurse in the surgical service (OP-Pfleger), surgeon's assistant , midwife and obstetric nurse, nurse in home care , Prosekturgehilfe etc.
Administrative service	6.4%	Commercial director, business economist , accountant , specialist in social and health services , commercial assistant , businessman in health care , businessman for office management , medical controller , coding specialist , press officer, secretaries, etc.
Economic and utility service	3.2%	Buyers , specialists for warehouse logistics , warehouse clerks, supply assistants , patient transport, waste officers , employees for waste disposal, pick-up and delivery services, kitchen staff , nutritionists , service staff , food distribution, housekeeping managers , laundry providers, textile cleaners , building cleaners , cleaning staff , security services, porters, etc.
Other personnel costs (e.g. clinical house staff, technical service, special services)	5.5%	Medical technician , technical manager, technical specialist , craftsman (e.g. electronics technician for building and infrastructure systems , system mechanic for sanitary, heating and air conditioning technology , gardener / horticulturist , painter and varnisher , caretaker ), IT system electronics technician , IT specialist , system administrator , specialist for Occupational safety , pastors , company doctor , company data protection officer , quality management officer, etc.

Material costs

Cost type	proportion of	Examples
Medical need	48.9%	Medicines , infusion solutions , medical and nursing consumables (gloves, syringes, cannulas, medical documents, wound dressings, etc.), blood , dialysis needs, implants ( e.g. implantable cardioverter defibrillator , pacemaker , vascular prostheses , stents ), medical instruments, laboratory supplies, anesthesia and Other surgical requirements, transplants, bandages, see also: List of medical products .
Maintenance eligible for maintenance	9.9%	According to § 4 Demarcation Ordinance (AbgrV), only the costs of services ( maintenance ) that were provided for the area of full and part inpatient hospital services and, in the case of revenue deduction, for pre- and post-inpatient services are eligible for care rates. This does not include the increase, significant change or extension of the useful life of the hospital's assets.
Economic needs	9.1%	Disinfectant requirements , cleaning requirements, laundry cleaning , garden maintenance, cultural material expenses
Administrative needs	6.7%	Office supplies (copy paper, envelopes), printed materials (forms, business forms), postage costs, bank charges, recruitment costs , broadcast post , telephone and provider costs, travel expenses , Literature, IT expenses (computers, printers, copiers, toner, software, data backup) etc.
Water, energy, fuels	6.5%	Wastewater , electricity , district heating , heating oil , natural gas , water , fuels (petrol, diesel, natural gas)
Other material costs	18.9%	Food, locum doctors , temporary workers ( temporary workers ), cost of rents and leases, insurance (eg. Business liability insurance , building insurance ), (for example, along with other hospitals operated devices. Also group subsidiaries) costs for central community services or costs of external service providers (for outsourcing of areas such as laboratory, cleaning, food supply, logistics, porter service, medical technology, craftsmen etc.), community taxes ( taxes , garbage collection , street cleaning ), disposal costs

Important laws and regulations

Book V of the Social Security Code (SGB V) - Statutory health insurance -

Hospital Financing Act (KHG)

Hospital Remuneration Act (KHEntgG)

Flat rate per case law (FPG)

Federal Care Rate Ordinance (BPflV)

Text of the hospital accounting regulation

Flat rate remuneration system for psychiatry and psychosomatics (PEPP)

Individual evidence

^ Service as a product, SAAP
↑ https://www.destatis.de/DE/ZahlenFakten/GesellschaftStaat/Gesundheit/Krankenhaeuser/Tabellen/KrankenhaeuserJahre.html
↑ Deutsches Ärzteblatt: State financing before the end (2004)
↑ New Caritas: Hospitals lack the money (2008)
^ The Cabinet Protocols of the Federal Government: 1966: Volume 19 - 1966, page 300, Oldenbourg Wissenschaftsverlag, ISBN 3-486-58960-1
↑ Questions and answers on the Hospital Structure Act , accessed on November 9, 2015.
↑ Criticism of the hospital reform, accessed on November 9, 2015.
↑ https://www.destatis.de/DE/ZahlenFakten/GesellschaftStaat/Gesundheit/Krankenhaeuser/Tabellen/KostenKrankenhaeuserBL.html

Hospital funding

contents

background

hospital

Former term of hospitals

General development

Health insurance

Overview of the forms of hospital financing

History of Hospital Funding

1945 to 1953

1954 to 1971

1972 to 1989

1990 to 2001

2002 to 2015

As of 2016

Current hospital funding

Health insurance

Annual budget

Revenue compensation

Psychiatric and psychosomatic hospitals

Federal states

Individual funding

Lump-sum funding

Basic flat rate

Performance flat rate

Hospital costs

overview

Personnel costs

Material costs

Important laws and regulations

Individual evidence

further reading