Hospital Structure Act

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Basic data
Title: Law to reform the structures of hospital care
Short title: Hospital Structure Act
Abbreviation: KHSG
Type: Federal law
Scope: Federal Republic of Germany
Legal matter: Social law
Issued on: December 10, 2015
( BGBl. 2015 I p. 2229 )
Entry into force on: predominantly January 1, 2016
Weblink: Text of the law
Please note the note on the applicable legal version.

The law to reform the structures of hospital care (Hospital Structure Act - KHSG) was passed by the German Bundestag on December 10, 2015. It includes extensive changes to hospital financing law. On the one hand, instruments were created to shape the hospital structure with the binding design of the quality requirements and the establishment of a hospital structure fund. On the other hand, numerous measures are aimed at the further development of operating cost financing. Further contents are the establishment of a care promotion program, the realignment of the quantity control as well as changes to the outpatient emergency care. With the Nursing Staff Strengthening Act , there were significant adjustments from January 1, 2019, including the nursing surcharge.

Legislative process

The key points of the Hospital Structure Act were drawn up by a federal-state working group, which presented its results on December 5, 2014. Her health ministers were Hermann Gröhe (Federation), Cornelia Prüfer-Storcks (Hamburg), Stefan Grüttner (Hesse), Melanie Huml (Bavaria), Monika Bachmann (Saarland), Barbara Klepsch (Saxony), Hermann Schulte-Sasse (Bremen), Cornelia Rundt (Lower Saxony), Sabine Bätzing-Lichtenthäler (Rhineland-Palatinate) and Barbara Steffens (North Rhine-Westphalia).

The draft law was introduced into parliament on June 30, 2015 by the government factions of the CDU / CSU and the SPD and, in some cases, decisively changed in over 40 places during the legislative process. The law was passed on November 5, 2015 with the votes of the government parliamentary groups against the opposition of the left and the Greens. It did not require the approval of the Federal Council.

Content

quality

Quality as a criterion in hospital planning

The Hospital Structure Act extends the catalog of objectives in Section 1 (1) of the Hospital Financing Act (KHG) to include the criterion of high-quality and patient-friendly care. The federal states have to implement this goal in their hospital planning.

In the new section 136c of Book V of the Social Security Code (SGB V), the Federal Joint Committee is commissioned to develop planning-relevant quality indicators for the quality of structures, processes and results by December 31, 2016. Provided that a state does not partially or completely exclude the application of these indicators by state law, they become part of its hospital plan and thus binding for hospital planning ( Section 6 (1a) KHG). Hospitals that not only temporarily fail to meet the quality requirements to a considerable extent are to be wholly or partially removed from the hospital plan ( Section 8 (1a) and (1b) KHG), provided that the respective state has not excluded the quality indicators relevant to planning in its hospital planning (Section 8 Paragraph 1c KHG). As a basis for decision-making, the Federal Joint Committee regularly transmits facility-related evaluation results from the cross-facility inpatient quality assurance to the federal states (Section 136c, Paragraph 1, Clause 2 of Book V of the Social Code).

Quality surcharges and discounts

The quality of inpatient care will also have consequences for hospital remuneration in the future (new paragraph 3a in Section 5 of the Hospital Remuneration Act - KHEntgG). Hospitals will receive surcharges for exceptionally good quality and discounts for quality defects. For this purpose, the Federal Joint Committee has to define a catalog of suitable services or service areas for the first time by December 31, 2017 and annually provide assessment criteria for extraordinarily good and for inadequate quality and up-to-date, facility- related evaluations of the quality data ( Section 136b (1) No. 5 and 9 SGB V).

The contractual partners decide on the application of the quality surcharges and discounts on site in order to be able to take facility-related features into account when making the decision. If the quality is found to be inadequate, the hospital will initially be given a year to correct the deficiencies before the deduction (twice the amount) is charged. If a hospital does not remedy the deficiencies within three years, the remuneration will be excluded (Section 5 (3a) KHEntgG).

Further development of the minimum quantities

The minimum quantity regulation is designed in accordance with the highest court rulings in a legally secure manner. Minimum quantities are justified if, according to scientific standards, a probable connection between the quality of treatment and the amount of service provided can be proven. The addition “in particular” has been deleted.

Further development of hospital financing

Care allowance

As of January 1, 2017, the care surcharge will replace the supply surcharge, which will be abolished as part of the realignment of quantity control ( Art. 3 KHSG). The annual financial volume amounts to 500 million euros, which is distributed among the hospitals according to their share of the nursing staff costs in the total nursing staff costs. Hospitals with higher nursing staff costs therefore receive a higher nursing surcharge than hospitals with lower nursing staff costs. The nursing surcharge is paid to the hospitals as a discount for each fully inpatient case. The original draft law provided for the deletion of the pension surcharge without replacement. The content of the discontinuation of the supply surcharge was due to the realignment of volume control and the elimination of the “double degression”, which it was introduced in 2013 to compensate. The hospitals and their employees protested against this plan. The introduction of the care allowance was then decided in the parliamentary legislative process.

Pro rata tariff refinancing

When negotiating the state base rates, either the orientation rate or the basic wage rate, if this is higher, is used. Additional wage increases were partially financed by the cost units in individual years (2008, 2009, 2012, 2013). With the Hospital Structure Act, half tariff refinancing is permanently established.

Clarification of the security surcharges

Security surcharges are used to finance the provision of necessary capacities that are not financed with the DRG case flat rates, but are required to supply the population. They were previously provided for by law, but the self-governing partners had not fulfilled their mandate to specify the application requirements. Therefore, with the Hospital Structure Act, the Federal Joint Committee is tasked with specifying the procedure for agreeing security surcharges by December 31, 2016 ( Section 136c (3) SGB V).

Further convergence of the state base rates

The range of the state base rates is to be reduced from 2016 onwards by further approximation to the uniform base rate corridor ( Section 10 KHEntgG). The adjustment is asymmetrical. The lower corridor limit will already be set in 2016 in one step from 1.25 percent to 1.02 percent below the nationwide base rate. The state base rates above the corridor (currently only Rhineland-Palatinate), on the other hand, are only to be brought up to the corridor limit of +2.5 percent, which was decided in 2009, within six years.

Further development of the calculation of the fee systems

The cost calculation for the maintenance and further development of the G-DRG system is based on the cost data of a sample of hospitals. So far, the participation of the hospitals has been voluntary, which leaves considerable doubts as to whether the costs are representative. So far, for example, the calculation of the investment valuation ratios B. no privately owned hospitals. This can lead to certain operations being remunerated too high, thus creating false incentives to perform these services. Therefore, the existing voluntary sample should be supplemented by the mandatory participation in calculation of individual hospitals ( Section 17b (3) KHG).

Funding programs

Foster care funding program

For the years 2016 to 2018, a care position funding program will be launched ( Section 4 (8) KHEntgG) for which € 110 million will be available in 2016, € 220 million in 2017 and € 330 million from 2018 onwards be asked. New hires and the increase in part-time positions in nursing, which have been taking place since January 1, 2015, are funded. The hospitals have to provide a self-financing share of 10 percent of the personnel costs. In this way, care in bed should be strengthened.

By the end of 2017 at the latest , an expert commission based at the Federal Ministry of Health is to develop proposals on how the need for care can be appropriately reflected in the DRG system or via differentiated additional fees and how the earmarked use of funds can be monitored with as little bureaucracy as possible.

Extension and expansion of the hygiene promotion program

The hygiene promotion program, which was set up with the Contribution Debt Act for the years 2013 to 2016, will be extended until 2019 and expanded to include the area of ​​infectious diseases ( Section 4 (9) KHEntgG).

Realignment of volume control

In the future, the degression of fixed costs will only occur where the cost advantages of the volume expansion due to the economies of scale actually occur. The replacement of the additional service discount by the fixed cost degression discount serves this purpose. For the hospitals, the additional service discount resulted in a "double degression" when services were expanded, since additionally agreed services were charged with the additional service discount at the level of the individual hospital and at the same time the fixed cost degression at the state base rate reduced the remuneration. To compensate for this double degression, the contribution debt law from 2013 introduced the pension surcharge.

As of 2017, the newly introduced fixed cost degression deduction will be charged with a three-year deduction on additional services ( Section 10 (13) KHEntgG). In contrast to the additional service discount, the lowering effect of additional services on the state base case value does not apply. The contracting parties agree on the amount of the fixed cost degression deduction by September 30th each year. For additional services with a higher fixed cost degression or for services that are subject to volume, a higher discount or a longer discount period must be agreed. In contrast, there is a legally stipulated catalog of exceptions with services for which the discount does not apply. These include B. transplants, multiple trauma, severely burned patients and the care of premature babies as well as services with material costs of more than two thirds. In addition, the contracting parties at the federal level are tasked with drawing up a catalog of hospital services that are not subject to volume (e.g. births) by July 31, 2016, for which a half discount will apply.

Establishment of a hospital structure fund

With the establishment of a structural fund, funds are to be made available for the years 2016 to 2018 in order to promote structural improvement measures in the federal states ( Section 12 KHG). In particular, overcapacities are to be reduced, hospital locations concentrated and hospitals converted into non-acute inpatient local supply facilities (e.g. health or care centers, inpatient hospices).

The structural fund will receive a one-off funding of 500 million euros from the liquidity reserve of the health fund of the statutory health insurance (GKV). In order to be able to take advantage of the structural funds, the federal states have to make an equal contribution. In this way, a volume of one billion euros is made available. The state participation must be in addition to the regular investment funding. For this purpose, the average amount of the regular investment expenditure for the years 2016 to 2018 must at least correspond to the funding for the years 2012 to 2014.

Outpatient emergency care

In the future, the associations of statutory health insurance physicians are to set up emergency service practices (" portal practices ") in or at the hospitals or integrate the emergency clinics of the hospitals into the contract medical emergency service ( Section 75 (1b) SGB V).

This measure was not provided for in the original draft law, but was only included in the law during the parliamentary legislative process under pressure from the German Hospital Association. This had pointed out that hospitals participate to a considerable extent in outpatient emergency care, the costs of which they are not adequately refinanced.

criticism

The assessment of the Hospital Structure Act differs among the various actors. All those involved criticize the fact that the reform omitted the problem of insufficient investment support. There are no fixed time horizons for

  • the implementation of an effective legal basis for investment promotion
  • improving the fulfillment of existing safety requirements, in particular hygiene safety
  • the balanced control of the quantity targets of the supply offers
  • the sustainable promotion of the quality objectives of the services
  • the sustainable promotion of the implementation of existing specifications for data security and availability of patient data

The German Hospital Society, which initially viewed the reform very critically, was able to push through key objectives in the parliamentary legislative process and, after the adoption, spoke of a "thoroughly historic" reform.

The health insurance companies generally welcome the increased focus on quality, but criticize the fact that they make billions in advance payments without knowing whether the quality promises will actually be kept. While the improvement in the financing of operating costs is due right from the start, the success of the structural change measures is not yet foreseeable. The health insurance companies therefore speak of a "missed reform", the solution approaches "lacking consistency, commitment and sustainability."

Web links

Text and synoptic representation of all changes to the Hospital Structure Act

Individual evidence

  1. ↑ Basic information in the documentation and information system for parliamentary processes
  2. ↑ cf. Section 137 (3) No. 2 old version and Section 136b (1) No. 2 new version of the Social Code Book V
  3. ↑ vdek factual paper on hospital reform , accessed on May 17, 2016.
  4. ↑ Ferdinand Rau - The hospital structure law in the overall view. The hospital 12/2015 ( Memento from May 17, 2016 in the Internet Archive ), accessed on May 16, 2016.
  5. ↑ German Bundestag of June 30, 2015 - Draft law of the parliamentary groups of the CDU / CSU and SPD Draft of a law to reform the structures of hospital care (Hospital Structure Act - KHSG). Printed matter 18/5372, pp. 56, 60. ( Memento from February 22, 2016 in the Internet Archive ), accessed on May 16, 2016.
  6. ↑ DKG: Billion deficit in outpatient emergency care - press release of February 17, 2015 ( memento of March 6, 2016 in the Internet Archive ), accessed on May 16, 2016.
  7. ^ Katrin Rüter de Escobar: Bundling forces against hospital reform. In: Das Krankenhaus 6/2015, pp. 530-533.
  8. ↑ Georg Baum: Editorial. The hospital 11/2015 ( Memento from May 17, 2016 in the Internet Archive ), accessed on May 17, 2016.
  9. ^ Stefan Wöhrmann: Hospital Structure Act. The missed reform. In: f & w 11/2015, pp. 911–914.