On Friday, the Bundesrat - which represents Germany's states - cleared the way for the controversial reform of hospitals in Germany to go ahead.
The plan - put forward by Health Minister Karl Lauterbach from the Social Democrats - has been in the works for two years and will signify a landmark change in the reorganisation of hospital health care in Germany.
The changes will be implemented step by step in the coming years. Lauterbach said it will fundamentally change the hospital landscape over the next 20 years, "and for the better," he added.
According to the Health Ministry, the aim is to ultimately reduce financial pressure on the 1,700 clinics currently operating across Germany, and ensure there is consistent standards for specialised care for patients.
"We will see more specialisation," said Lauterbach. "At the same time, we will see that small hospitals in rural areas can make a living from what they do particularly well."
The move has proved controversial, with several politicians from German states criticising the reform in the Bundesrat debate on Friday.
North Rhine-Westphalia's health minister Karl-Josef Laumann (CDU) warned that the requirements for specialist doctors in rural regions were not achievable at the moment. What is needed is "more room to manoeuvre" for states when it comes to implementation, he said.
Some patient groups have also voiced their opposition to the reform.
However, there is support, too. Rhineland-Palatinate health minister, for instance, Clemens Hoch (SPD) campaigned in favour of the reform.
A ‘transformation fund’ worth billions is to be set up to provide financial support for the reorganisation.
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New remuneration system planned
Currently, German hospitals receive a flat rate per treatment or patient, which has put clinics under economic pressure to see increasing numbers of patients.
In future, these flat case-by-case rates will be reduced and, instead, hospitals will receive set sums based on the services they provide, such as staff, an emergency admission or necessary medical technology. Under the new law, they'll receive up to 60 percent of their remuneration for providing specialist services.
This is intended to eliminate incentives for medical interventions that are not always necessary, the Health Ministry says.
Focus on specialised treatment
New ‘service groups’ will form the basis for financing from health insurance organisations. They are intended to describe hospital treatments more precisely and ensure uniform national quality standards for them when it comes to specialist staff or treatment experience. For instance there may be reference to "cardiology" in future instead of broad terms such as "internal medicine".
Some hospitals will in future also be allowed to offer outpatient specialist treatments. This would be the case if there is no corresponding specialist in a region. This means that the long journey to a specialist practice, which is the case in some places, should no longer be necessary.
Better accessibility
On the note of getting to a clinic, the reform stipulates that patients should be able to drive to internal medicine and general surgery wards in a maximum of 30 minutes, with travel time for other hospitals not exceeding 40 minutes’ drive time.
Will some hospitals close?
Lauterbach told German media in October after the reform was passed by the Bundestag (German parliament) that a number of hospitals will close due to the changes.
"It is quite clear that we will have a few hundred fewer hospitals in 10 years at the latest," he told Bild am Sonntag. Hospitals in large cities in western Germany are likely to be particularly affected, Lauterbach said.
However, he said: "We don't have the medical needs for these hospitals,", adding that every third bed is empty and there are not enough staff. Lauterbach emphasised that urgently needed hospitals in rural areas would receive additional funding in order to survive.
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