Cost containment: Europe. Germany.

The German healthcare system offers a social network guaranteeing almost complete healthcare coverage to the German population (prevention, treatment, and rehabilitation). The system is supported by a multistructured network of public and private healthcare insurers. Fees for public insurance are equally paid by employers and employees. Healthcare expenditures heavily impact the salary levels of employees and, as a result, production costs of employers. About one third of all national healthcare spending goes to hospital care. In 1991, there were ICUs in half of all German hospitals; 3.2% of all hospital beds were ICU beds. As in most countries, the expansion in national healthcare costs in the last decade has become a serious problem in Germany. At total of 8.1% of the entire German gross national product is spent on health care, which has led to drastic governmental healthcare reform that began in 1993. The key points of this reform are: a) strict limitations on hospital budgets at 1992 levels including a new structure of hospital financing; b) controlled reduction of expenditures for medical drugs (which were formerly at the highest level in Europe); and c) controlled restriction of regional distribution for physicians. In a large German university hospital (1,461 beds; 91 ICU beds) expenses for intensive care medicine comprise about 12% of all hospital spending (5,356 deutsche mark/patient). More than 60% of these expenses are for personnel; 37% go toward drugs and medical materials. There are several possible starting points for cost containment in intensive care medicine in Germany: a) a task-adapted, countrywide diffusion of ICUs within the different levels of hospitals; b) a more selective provision of intensive care medicine (primary as well as secondary) to patients, depending on patient needs; c) a centralized and task-oriented admission and discharge policy; and d) cost containment in the use of drug therapy by centralized hospital purchasing and by establishing strict, rational, therapeutic principles. Some examples of the author's personal experience follow. In all German hospitals, expenses for personnel are about 60% to 70%. These expenses are fixed by official, standard wages. Cost containment by further restricting the number of personnel impairs the care provided. Improvements in organization and management may contribute to a higher degree of personal motivation for employees and, in turn, may result in higher working efficiency.