At least on one point everyone seemed to agree from the start: Germany's hospital landscape urgently needs to be reformed.

Because there are an above-average number of clinics and an above-average number of beds in this country, but something is going wrong in the care.

But what should the reform look like?

And: Who should actually decide which hospitals will offer which services in the future, how much money will they receive for them – and which ones may have to be closed?

These questions got tricky.

Britta Beeger

Editor in business and responsible for "The Lounge".

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On Thursday, the health ministers of the federal and state governments as well as health politicians from the Berlin traffic light coalition met for the “Hospital Summit”.

Specifically, it was about the proposals of a government commission set up by Federal Minister of Health Karl Lauterbach (SPD) made up of doctors, economists and lawyers for a new structure and financing of the around 1900 clinics in Germany.

In principle, there was a lot of approval for the recommendations of the commission.

However, some federal states - above all North Rhine-Westphalia and Bavaria - complained that their competences were being encroached upon: According to the Basic Law, hospital planning is a state matter, they complained.

And she must remain so.

Joint bill by the summer break

So there was a lot to talk about, so much that the meeting lasted much longer than originally planned.

Lauterbach and his two colleagues Karl-Josef Laumann from North Rhine-Westphalia and Daniela Behrens from Lower Saxony then announced that they had decided on an unusual approach: The federal and state governments want to work out a joint draft law for a hospital reform by the summer break.

It will be a law that requires the approval of both the Bundestag and the Bundesrat.

The federal government usually draws up a draft for such a law, which is first passed in the Bundestag and only then discussed in the state chamber.

One can therefore assume that the countries emphatically insisted on their responsibility for hospital planning at the meeting.

It has become clear that this "remains with the federal states for good reasons," said Laumann, citing his own federal state as an example.

The hospital structure in the Rhineland is different from that in the Westphalian part of the country, and the same applies to western and eastern German states.

One cannot "put a federal template over the hospitals," said the CDU politician.

Federal Minister of Health Lauterbach particularly emphasized the points on which there was agreement and spoke of a "great meeting".

Consensus prevails in the problem analysis.

60 percent of hospitals have significant financial problems, he said.

"Without a major reform, many hospitals would go bankrupt." There are also major quality problems.

In many places, care cannot be provided in the required quality.

Case flat rates should play a lesser role

But even if there is agreement on the problem analysis and all sides emphasize that a good working structure has been found: In the coming months, the federal and state governments are likely to face many difficult debates about the details of the planned reform, which, according to Lauterbach, will be nothing less than a "revolution “ represents in the clinical system.

The aim of the reform is that in future patients will be treated more according to medical than economic criteria.

According to the government commission's proposals, the case-based flat rates that hospitals have received per patient and diagnosis in the past should play a lesser role in the future because it is widely believed that they lead to false incentives.

On the one hand there are too many unnecessary surgeries, but on the other hand pediatric wards have to close,

because they don't make economic sense.

The clinics should receive fixed amounts for the provision of staff, medical equipment or an emergency room.

In addition, the hospitals are to be divided into three categories – basic providers for basic care, standard and priority providers for more complicated interventions, and maximum providers such as university hospitals – and divided into different performance groups and rewarded accordingly.

Because not every hospital will offer everything in the future, the quality of care should also increase.

According to the Federal Ministry of Health, strokes are too often treated in clinics without a stroke unit and oncological diseases in houses without a certified cancer center.

Lower Saxony Minister Behrens from the SPD described the government commission's proposals as a "working basis", but they would not be translated one-to-one into a government draft.

The reform is a mammoth task, said Behrens.

However, it is indispensable because there are already gaps in care in rural areas and because many doctors and nurses will retire in the coming years.