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BERLIN - German politicians invited to speak at the centennial Congress of the German Ophthalmological Society did little to allay concerns for approaching changes in the national health care delivery system.
Peter Schmidt, health care spokesperson for the newly elected Social Democratic Party (SPD) majority, outlined plans to improve health care, re-direct funds, and 'chop off the fat'.

"We at the SPD choose to adopt a policy of 'quick and dirty' health reforms rather than repeat the sluggish ineffective changes we saw in the last four years," Mr Schmidt said.
Beginning in January next year, health reforms are to be phased in and modulated in accordance with the needs of doctors and patients. Although it sounds flexible enough at face value, some analysts suggest there is really little room for discussion.

Essentially, Mr Schmidt warned that the health care system will be asked to do the same job it has been doing but with less money.

"Sometimes the agenda for change must take the business side of health into account more than the medical side in order to fit budgetary requirements," he said.
German doctors are bracing themselves for these reforms which many believe will be bad for both doctors and patients. Ophthalmologists at all levels and in all kinds of working capacities, from medical students to university clinic residents, research fellows and private practitioners, are likely to feel the pinch.

German politicians have deemed the polyclinic the institution of the future. They are certain the German polyclinic will not follow the Spanish, Greek and Italian models in which patients travel long distances to visit large impersonal polyclinics and wait long hours to be treated in a few short minutes. But German physicians do not hold the same faith.

Director of the Frankfurt University Eye Clinic, Christian Ohrloff MD, said it is already difficult to find young medical graduates who are willing to specialise.
He said medicine has turned into an unattractive occupation which offers young people poor prospects for an interesting career with the possibility of a lucrative future. The changes to be wrought in the private sector here will only worsen their outlook.

He stressed the necessity for private practice to provide adequate health care and fulfil young doctors' desire to be independent. Dr Ohrloff was also concerned that these reforms will not just discourage young doctors going into private practice but will generally keep them out of the clinics and research institutes as well, which will have most dire effects on the progress of medicine.

Young doctors entering pharmaceuticals or signing up with medical insurance companies have fully or partially government-funded positions. Others argue that the funds at hand need only be directed back to the hospitals.
The system of diagnosis-related groups (DRGs), currently used in many countries including Australia and the US, is to be adopted as a guideline in polyclinics and hospitals for patient care.

DRGs precisely define and group medical symptoms, diseases, procedures and treatment plans, each with a specific budget.
There is concern among the German ophthalmological community that DRGs will not allow a differentiated treatment of patients due to the improper and unrealistic grouping method.

DRGs categorise eye diseases into 18 budgeted categories which pay alike, putting a three hour retinal procedure or a strabismus operation, normally performed in several sittings, on the level of other much shorter and less complicated procedures.
While German doctors fret over what might mean the "blutige Entlassung" - or "bloody release" - of their patients, health care officials believe patients stay beyond the requisite time in hospitals which have too many beds to begin with.

The average stay in German hospitals is 9.8 to 9.9 days, while a hospital stay in the US averages at five to 5.5 days. The average German hospital has 6.5 beds per 1,000 population, while the US average is four to 4.5 beds per 1,000 population.
Some doctors argued that although ophthalmology has evolved into one of the most ambulatory specialties, there are other patients who require longer hospitalisation. Releasing them from hospital before their time would be unethical and irresponsible, they stressed.

Mr Schmidt reassured listeners that the DRG system is a "learning system" which must be modified from the original model to fit German needs.
Other proposed reforms included the formation of hospitals and clinics that offer care in a specific specialisation only.

In this way, patients supposedly will have the option of highly specialised physicians which will effectively do away with mediocre health care. It will also streamline expenses by ending the need for patients to get second opinions.
Although the budget will remain the same through 2004, the SPD plans to put their reforms into action by 2005.

They plan to implement the reforms in all German states, no longer permitting local health care decisions to be made.
The news of universally instituted reforms may be particularly damaging to some states which had once managed to negotiate better deals locally for out-patient surgery.

In Hessen, for instance, ophthalmic surgeons have offered excellent care to their out-patient cataract patients, while securing a reimbursement which was much more efficient than in neighbouring states. Bavaria is another example of favourable local health management.

In the face of the "quick and dirty" reforms promised, some German ophthalmologists would opt for privatising the system.
They argue that it seems unlikely that a real balance can ever be found and that the system keeps imposing more and more restrictions. Basic health care should be provided with optional procedures paid for by the patient, they reason.
Mr Schmidt was resolute that the SPD would never condone a system that left the choice for medical care up to the patient.

"People will obviously opt to go to the Maldives on vacation before they use their money for an operation. We cannot allow that kind of system in Germany. Comprehensive health care must be provided in a fair civic-minded society," he said.
Mr Schmidt was the only one of the three politicians asked to represent their party's views at the Congress. The invited spokespersons for the Christian Democratic Union (CDU) and the Free Democratic Party (FDP) did not attend.

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