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Figuratively speaking I'm actually two or three doors down, have only ever been to Italy for any significant length of time once in 1993, and luckily never needed medical treatment there, so I'm just as much an outsider. But as a general observation, the current articles going on about Italian "socialized healthcare" seem to have the same motivation to me as those trying to pin responsibility for the situation in the US (whatever it is) on the Trump administration - just in reverse, by arguing "this is what Democrats would foist on us". Either camp is trying to make partisan hay with a global health crisis, which is pretty ghoulish IMO.

I have noted that those articles really have to tie themselves into pretzels to make their case, and as I said when I saw the first tweet about "socialized Italian healthcare" posted, let's come back to that in two weeks. Meanwhile, I'm somewhat well-acquainted with the German healthcare system via family; dad was a surgeon, brother #2 served at the Berlin military hospital (which are tied into the civilian system to generate revenue here - how's that for market orientation) as an air force surgeon for about 20 years and now works in controlling for a major national hospital operator, and his wife is an internist now working in political liaison for the Federal Medical Council. If I get around to it, I might start a separate thread on comparing different healthcare systems, since this one is already pretty bloated. As we seem to have various medical professionals here, it should be interesting.

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The Battle Begins

Are Hospitals Ready for the Coming Wave of Corona Cases?

The German health-care system is considered one of the best in the world. But the corona-virus is mercilessly exposing its weaknesses, with some hospitals already facing difficulties. Can Germany prevent the kind of collapse seen in Italy?

21.03.2020, 10:58 Uhr

By Matthias Bartsch, Jörg Blech, Annette Bruhns, Lukas Eberle, Katrin Elger, Markus Feldenkirchen, Kristina Gnirke, Annette Großbongardt, Hubert Gude, Veronika Hackenbroch, Julia Jüttner, Martin U. Müller, Cornelia Schmergal and Steffen Winter

The man with the white shock of hair in Room 4 of the intensive care unit wasn’t able to breathe. But now, a tube has been placed in his throat and oxygen is flowing into his lungs. You can see through the window on the door to the room how his chest is moving up and down in time with the ventilator, 28 times a minute. The 83-year-old is fighting the SARS-CoV-2 virus.

It’s Monday, and during the course of the day, nurses and doctors have to watch as his condition deteriorates. They notify his wife and daughter, who arrive around noon. Under the new rules for these corona times, only one relative is allowed into the isolation room for 30 minutes. The woman sits beside her husband in full protective clothing and gloves and places one hand on his forehead and one near his heart. The head of the ward responsible for care decides to bring the daughter in as well. He equips her with protective clothing and lets her go to her father. Both are permitted to sit there for as long as they want.

The man passes away at 3:15 p.m., with the resident issuing the death certificate. The immediate cause of death given: "Hypoxic respiratory failure. A complication stemming from COVID-19 pneumonia."

The man passed away at St. Antonius Hospital in Eschweiler, North Rhine-Westphalia, only 30 kilometers (19 miles) from Heinsberg, the largest known cluster of infections in Germany to date. A ventilator was available for him, but the help came too late.

There’s some good news and some bad news for people in Germany right now. The good news is that Germany is home to one of the most modern, richest and most powerful health-care systems in the world. We have an "excellent health-care system, perhaps one of the best in the world,” German Chancellor Angela Merkel said in her address to the nation on Wednesday night. It is better equipped for dealing with the corona epidemic than the systems of many other countries.

The bad news is that large parts of this system are already overwhelmed. Depending on how fast the number of infections increases in the days and weeks to come, we could experience a collapse and failure of the system. And it will be deemed to have failed if people have to die because of a shortage in staff, beds and equipment -- and not because this illness is incurable.

[...]

In recent days, a chief physician from the Rhineland had to admit to a colleague that he only has seven ventilators at his hospital. He said he needs 13 in order to get through a major wave of serious infections.

And that wave will come - that much is certain. "We expect that things will really heat up in the next two weeks, also here in Germany," says Axel Fischer, managing director of the München Klinik, a Munich-based chain of hospitals. His hospital treated the first patients infected with the coronavirus in January. He fears the crisis will have a "massive impact.”

The coronavirus is mercilessly exposing the problems that have been burdening the German health-care system for years: the pitfalls of profit-driven hospital financing. The pressure to cut spending. The chronic shortage of nursing staff. The often poor equipping of public health departments. The lag in digitalization.

"We are preparing for imminent catastrophe,” says Rudolf Mintrop, head of the Dortmund Klinikum, the city’s main hospital. He calculates that the wave of sick will hit hospitals at full force in 10 to 14 days. The chancellor has warned that German hospitals will be "completely overwhelmed" if too many patients with serious coronavirus infections have to be admitted within a very short period.

Ultimately, the question of life and death will be decided in the intensive care units. The answer will depend on how many ventilator beds there are, how many doctors are on call and how many nurses are able to provide care for critically ill patients.

To prevent a collapse of intensive care units, the German federal and state governments have taken drastic measures that are bringing public life in the country to an almost complete standstill. They have closed stores, sealed borders and shuttered schools, daycare centers and playgrounds.

One of the primary reasons for the steps taken is the imminent shortage of ventilators. German hospitals currently have access to around 25,000 deployable ventilators. The federal government is making efforts to acquire thousands of additional devices, but their manufacture and delivery may take time. There are far more of the devices available in Germany than in Italy and there are also more health-care workers to operate them. But doctors and medical experts still fear supplies could fall short here.

The number of infected in Germany who will have to be provided with artificial respiration will depend on whether people get serious about what virologists and politicians have been warning about for weeks: social distancing. The more consistently all contact is avoided, the greater the chances are of slowing down the rapid rise in new infections.

Another determining factor will be whether doctors and hospital directors go along with the government’s request that they clear their wards in preparation for the expected onslaught of coronavirus patients, particularly given that there is often already a lack of nursing staff and equipment even at hospitals that are operating under normal circumstances.

Under the German Social Code, health-care providers are required to promise every insured patient an economical and efficient treatment based on state-of-the-art knowledge. It does not entail any restrictions. "Rationing” is a word that has never been heard before in our postwar health-care system. But it appears to be one that people in Germany might have to get used to, right along with the even scarier word "triage.”

In any case, the fight against the virus in German hospitals has already begun. The coming weeks will determine whether it can be won.

Intensive Care Beds

Last week, German Health Minister Jens Spahn sent a personal letter to the managing directors of almost 2,000 hospitals in Germany. To keep enough intensive care beds free, he requested: "In principal, all operations and procedures that can be planned in advance are to be postponed and suspended immediately in all hospitals, from Monday onward.” Almost pleadingly, Spahn asked for doctors to be brought out of retirement, for students to be hired to help and for more intensive care beds to be made available. "Now!"

Some hospital bosses like Michael Albrecht at University Hospital in Dresden followed suit. The hospital said beds would be deliberately cleared and operations postponed if possible. "But it’s hard to decide sometimes,” says Albrecht. "Should a necessary tumor operation be postponed because of corona?" He says you can set priorities, but you can’t make overly hasty decisions.

"Right now, we’re only postponing operations if the patients won’t suffer disproportionately as a result,” says Andreas Meier-Hellmann, the head of the coronavirus crisis team at the Helios Kliniken chain of private hospitals. Helios is also permitting tumor operations to go on "even if the patients might have to be put in the intensive care unit afterward.”

Many hospital managers are actively ignoring Spahn's appeal. This could in part be due to the fact that their facilities are under economic pressure and depend on the revenues provided by procedures like knee prostheses, hip replacements or heart catheter examinations. These kinds of procedures, which experts say are often unnecessary, are the most lucrative for the hospitals.

[...]

Nursing Shortage

It’s in the nursing divisions that Germany is currently the most ill-equipped for dealing with the crisis. One 50-year-old nurse who works in an intensive care unit at a university hospital in Lower Saxony says she and her colleagues were already pushed to their limits before the coronavirus struck. She asked to remain anonymous out of fear of reprisals. "The system actually doesn't have any buffers anymore, and we often exceed our capacity."

She says some of the intensive care beds in her hospital can’t be used because of a lack of staff. When she first started working in the field 25 years ago, she says, one nurse was responsible for taking care of one or two ICU patients, but now that number is two or three. "We're writing overload reports that should be called danger reports." At the end of the shift, she sometimes feels her feet are "three times as thick, and as if somebody beat me up. Then I practically crawl home.”

The nurse sees serious ethical conflicts ahead for society. "Everyone has become accustomed to the maximum care system, under which everyone gets everything they can." But this cannot be sustained if the number of critically ill people increases as feared.

It’s a problem that Health Minister Spahn has identified. A law was passed requiring hospitals to have a minimum number of nursing staff in 2018. But it has barely gone into effect, and Spahn will now have to suspend it again -- otherwise the hospitals won’t be able to cope

The staff shortage in German hospitals is chronic, with at least 17,000 nursing positions vacant in the country. The hospitals share some of the blame for this state of affairs. They’ve been cutting back spending in recent years, especially on nursing staff. At the same time, the German states have withheld billions of euros from the hospitals that should have been spent on investments in infrastructure.

"The reductions in beds and staff shortages didn’t occur suddenly and unexpectedly," says Asklepios Group works council Chairman Martin Schwärzel, whose organization represents employees in the hospital chain. "The number of nursing staff in the clinics was used as a key financial figure in the hospitals and was reduced as far as possible. Now, everyone is working at their limit."

[...]

The Lessons

Germany, which exalts about having one of the world’s best health-care systems, has a number of dangerous weak spots. Contrary to popular belief, the system has not been starved by budget cuts. Instead, health spending has been going up for years. Between 2009 and 2019, Germany’s spending on public health insurance has risen from 167 billion to 246 billion euros.

But the money was often channeled to the wrong places, to radiologists and orthopedists instead of general practitioners, who represent a desperately needed place of first resort for rattled patients. And the money has definitely not gone to the nurses.

The poor monetary distribution has a lot to do with the financing of German hospitals. Since 2003, hospital services have been remunerated on the basis of set prices for procedures, according to which hospitals receive a set amount of money for every knee or spinal surgery -- no matter how many days the patient has to spend in the hospital, or the extent of his or her care. For hospital managers, this means pre-scheduled operations are the best way to make money, provided that as little as possible is spent on care.

And as a result, Germany, one of the world’s richest industrialized nations, has operating rooms with cutting-edge technology, but fewer nurses per hospital bed than Estonia or Slovakia. Karl Lauterbach, a respected health-care policy expert with the center-left Social Democrats, puts it in dramatic terms: "Since the implementation of the set prices, a doctor has become an investment, but nurses are a financial burden.” For years, the health economist has warned that the set-price policy increases incentives for poor care.

Doctors are also suffering under the system. "For years now, hospitals have been subjected to an industrial logic. But it doesn’t make any sense to run hospitals like factories. It cannot primarily be about money,” says Peter Hoffmann, the chief physician at a Munich hospital and chairman of the Association of Democratic Doctors, which views itself as a counterpoint to the traditional doctor’s associations.

"We will not simply be able to return to everyday life after this,” says München Klinik Managing Director Fischer. "We will need to conduct a review of our entire health-care system."

Perhaps a pandemic was needed to come to that realization.

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Originally posted by icom706:

I read a piece in the WJS 20 years or so back talking about how the private sector health care system here was moving toward rationing health care...