Der Sicherstellungszuschlag für deutsche Krankenhäuser - Garantie für gleichwertige, wohnortnahe Gesundheitsversorgung?
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Philipps-Universität Marburg
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Abstract
Background: The German inpatient healthcare system is undergoing continuous transformation. Public discourse prominently features the closure of rural healthcare facilities, which adversely affects local (emergency) care. Many hospitals in sparsely populated regions cannot operate cost-effectively under the current reimbursement system due to low case numbers. To ensure comprehensive and equitable healthcare across all regions, a security surcharge (ger. Sicherstellungszuschlag) was introduced in 2020. This surcharge accounts for the maintenance of certain healthcare structures but does not consider the quality of care. This raises the question of whether the security surcharge ensures widespread coverage without guaranteeing optimal quality of care and whether considering hospital quality would lead to a different selection of "suitable" hospitals.
Research Question, Material, and Methods: This study examines whether the hospitals receiving the security surcharge demonstrate the best quality of care or if there were more suitable alternatives in the affected regions, based on structured quality reports (ger. strukturierte Qualitätsberichte) from 2018 and 2019. The analysis investigates whether hospitals receiving the security surcharge from 2020 have a different quality level compared to facilities within a 50-kilometer radius that could serve as alternatives based on their structural characteristics and location. The analysis focuses on quality indicators in internal medicine, surgery, gynecology and obstetrics, as well as nursing. The results of the quality indicators from the structured quality reports are converted into relative sizes and categorized based on their percentile ranks for the respective hospitals. Additionally, a quality-based comparison is made using other structural characteristics.
Results: Approximately half of all security surcharge -receiving hospitals exhibit poorer overall care quality compared to the alternative facilities used for comparison. About one-third of the subsidized hospitals have equivalent overall care quality, and only around 20 percent perform better than their alternatives. A similar pattern emerges for almost all subcategories. For categories primarily related to structural aspects (regions, ownership, size, rurality), the comparison was based on overall quality again. Additionally, comparisons were made regarding emergency care levels and technical equipment. Here too, security surcharge facilities generally perform worse than their alternatives, with few exceptions. Notably, a U-shaped relationship is observed concerning overall quality in relation to hospital size. Discussion and Conclusion: The original security surcharge allocation criteria do not consider the assessment of quality of care. Since ensuring comprehensive medical care is the primary goal of the security surcharge, it should not be disbursed in regions with locally available alternative facilities. The poorer quality of care of security surcharge hospitals could also be attributed to insufficient financial resources, as the lack of monetary resources hinders the funding of quality-enhancing measures. However, for some subcategories, it must be considered that very low sample size could distort the results due to random influences. Financial constraints of security surcharge facilities may have led to cutbacks in provisions relevant for emergency care level assignment before the surcharge's introduction. Access to emergency care structures is a crucial aspect, especially for comprehensive coverage.
The current security surcharge allocation appears sensible only for a small number of affected facilities (island hospitals or clinics without regional alternatives). The presence of locally available alternative facilities, which largely ensure better quality of care, calls the current allocation into question. It is also unclear why hospitals with a high number of beds cannot ensure sufficient independent financing through their resulting case numbers. In structurally weak regions, the security surcharge could be an adequate means to ensure comprehensive inpatient healthcare. Currently, the assessment of jeopardizing comprehensive coverage seems inadequate, as there are many alternatives within a short radius. For efficient use of funds, this must be ensured in the future. The saved financial resources could potentially be invested in expanding emergency rescue structures.
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Dates
Created: 2025Issued: 2025-03-13Updated: 2025-03-13
Faculty
Medizin
Publisher
Philipps-Universität Marburg
Language
ger
Data types
DoctoralThesis
Keywords
Qualitätsvergleich von KrankenhäusernSubventionierung im Gesundheitswesencomparison of quality in hospitalsSicherstellung medizinischer Versorgungensurance of medical caresubvention in the health system
DFG-subjects
QualitätsvergleichSicherstellungszuschlagGesundheitsversorgungsforschung
DDC-Numbers
610
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Kaiser, Lea Theresa Maren: Der Sicherstellungszuschlag für deutsche Krankenhäuser - Garantie für gleichwertige, wohnortnahe Gesundheitsversorgung?. : Philipps-Universität Marburg 2025-03-13. DOI: https://doi.org/10.17192/z2025.0152.
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Except where otherwised noted, this item's license is described as Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 - CC BY NC ND