“Medicine of relatedness” rather than diagnosis related groups

Corona should be a wake-up call

Interview by Britta Fecke, German broadcast “Deutschlandfunk”, with Professor Giovanni Maio, M.D., medical ethicist

Britta Fecke: This pandemic, this state of emergency, reveals what is really important: well-equipped hospitals for instance, sufficient numbers of intensive care beds and most of all, medical personnel not constantly working at the brink of their limits. On 18 April 2020, Klaus Reinhardt, president of the German medical association, stated that “… Hospitals need to serve their patients, not the profit” and he demanded a new financial model for the time after corona. Professor Giovanni Maio is a medical doctor, philosopher and well-known of his outspoken criticism of the German medical system. I wanted to know from him whether hospitals face problems in the crisis due to the long years of economy-driven health care.
Professor Dr Giovanni Maio: Yes, this is obviously a big problem! Basically, we are presented with the bill for recent years right now. The concept of capitalising medicine and medical care has resulted in a deficiency that cannot be overlooked any longer: deficiency of personnel and deficiency of resources. We have set wrong priorities for saving money and now we have dangerous deficiencies because of our wrong thinking. We had postulated that medicine should work no different from an industrial enterprise, where everything is fine so long as money gets invested wisely and sustainability is defined in economic terms. But this is wrong thinking – medicine just is no industry but part of the social fabric, in essence a practice of forehandedness and this social practice is governed by laws different from those of the economy. We had been wrong on this one.

We have set wrong priorities –
the result: wrong thinking

In what way is this social logic violated by the diagnosis related group (DRG) reimbursement system?
The DRG system was deleterious. It opened the gates for a thorough capitalisation, in that hospitals were urged to save money at any costs. And saving money they did, but not sensibly but with wrong priorities. They cut personnel costs, they cut personnel patient interaction time, they created a care time deficiency thereby evoking stress and reducing the job satisfaction of nursing professionals. At the same time, the DRG system encouraged hospitals to generate business volume and that turned the whole philosophy of medicine upside-down. Suddenly the question to ask was no longer: What helps the patient, but: What kind of business volume can we generate with this case? And this is wrong thinking which in my opinion never should have been allowed to take root because the medical professions wouldn’t have any of that from the beginning. This was wrong thinking, established by the reimbursement system. Nobody considered that a whole culture would be altered that way, and so they kept doing what lead to more reimbursement, many operations because they generate business volume but at the same time cutting time for patient contact, for relatedness. This was a wrong orientation of medicine!

 “I do hope that corona will be
understood as a call-to-action”

This disorientation may be reflected by the current practice that the economic director often is higher in the chain of command than the medical directors. Do you expect this to be reversed again after corona? That now, after we have found out how important a functioning healthcare system is for our societies, things will be put in a different perspective?
I do hope that corona – tragic as it is – will be understood as a call-to-action, as a wake-up call which shows what is important. It is reasonable to have economic expertise in hospitals, but economy needs to serve as a helping hand for medicine to live-up to what medicine should be like – economy should not define what medicine should or shouldn’t do! And we should learn from current events that there is a social sphere which might necessitate economic reasoning but should not be restricted to just this aspect. Thinking in mere reimbursement categories is wrong thinking. Now we see how badly we need the hospitals! Just imagine that many hospitals might go bankrupt at the very time when they are needed most, this reveals at once how distorted this reimbursement system has been. A hospital which is more desperately needed than anything, might be driven into insolvency because there is not enough reimbursement – crazy!

 “The market will not solve
the social problem”

We need to acknowledge that hospitals should be financed by the state and by the health insurance companies with the aim to provide for the care of the population. Imagine that only a few weeks ago it was propagated that half of our hospitals should be shut down for economic reasons, now the craziness of that thought is open to see for everybody. We must never create a deficiency in that precious resource of patient care time, only for the sake of hospitals always to be in the black! It is up to the state to guarantee that hospitals get the resources they need, and to rule where hospitals should be situated and which services they should offer to the population. And this cannot be determined by economic analyses, but the question is, where are hospitals necessary and where unnecessary. There are political decisions which can never be made by the market. The market will never solve the social problem, let´s face that.

Promoting a “medicine of relatedness”

But we cannot blame everything on the political class. Many patients misunderstood themselves as customers of the health care system and used or rather abused it in the wrong way. There are more than 500 million patient physician contacts per year in Germany! That makes one wonder, where all these diseases might come from.
Well, you see, first of all we have to acknowledge that patients demand to make decisions themselves nowadays. It is our task to help them make good decisions. And we must establish a system without misleading stimuli, for instance the stimulus that it is worth doing things just for the sake of doing them, such as: as many operations as possible. This stimulus is deleterious. In my opinion, such stimuli challenge the very essence of medicine and may lead to a situation where doctors recommend procedures because they get reimbursed for them. I think one has to create stimuli for a medicine of relatedness, for a medicine of care and stewardship rather than doing anything for reimbursement. And patients are per definition in a situation where they cannot objectively analyse all facts and decide what is best for them. They depend on the experts and have to rely on their advice, therefore we need to use the tools we have in order to encourage the experts to act responsibly. And in this regard, we had established a culture of misleading stimuli which had negative effects on the whole culture.

“The whole purpose of medicine is to help people”

What would be a feasible alternative approach? If we want to replace this reimbursement system which rewards a philosophy of “the more the better”, i.e. more CAT scans, more MRT, more operations leads to more reimbursement for the economy-driven hospital – so, could an alternative approach perhaps reward the number of people who stay healthy in an area which belongs to a certain hospital? Does this sound intriguing to you?
No, not at all. Look, this may sound appealing, but we should not expect medicine to produce as many healthy people as possible. The purpose of medicine is to help those who cannot help themselves, these are per definition often chronically ill patients, incurable patients, these are sick patients who just cannot get cured. At the end we must leave it to the logic of medicine to figure out what approach is best in each individual case. We have to appeal to professionalism and liberate medical doctors to once again be guided by medical criteria alone. What we see today is a deformity, a misshaping of medicine by criteria alien to medicine as such, which have little to do with medical logic. That’s why we need to strengthen professionalism. A patient wants to be treated by a medical doctor who follows the guidelines of his textbooks rather than what reimbursement policies suggest. And this is a crucial point: We have in fact down-rated professionalism. Part and parcel of professionalism in medicine is the ability to build relatedness, to invest in the relation, one needs to listen a lot at first, in order to figure out what the problem of the ill human being is, because in most cases this mischief cannot be solved by a single procedure but requires care and stewardship, one simply has to spend time.

“We need a system that rewards patient care”

We need a system that rewards those who spend actual time with and care for patients – currently we have the exact opposite. Because the lack of human resources we are facing today – that neither medical doctors nor nurses have enough time – has been artificially implemented, it is not unavoidable, an artificial stress. In my opinion this is grossly negligent, that these professional groups who are so important for the well-being of the society have been put under such pressure – for no reason! There was no good reason for this, really! Instead, this new reimbursement modality lead to rising costs, we did not even save money, since all that was done was operating on patients rather than talk to them – such a system is crazy!

The diagnosis related group system has failed

That means, regarding the concerns, that are often voiced, such as: “If we completely restructure the health care system everything will get more expensive”, you would reply: “Not necessarily, because many operations and procedures that had been performed without compelling reason will be avoided and this will save costs.”
Absolutely, you put it exactly right. When it all started political support for the DRG’s could only be obtained by arguing: “If we don’t do it everything will become more expensive.” But that was not true. Costs did not rise. Not in reality, at least, just as a media hype. Costs exploded only afterwards: Due to the DRG’s mainly costly procedures were performed. And costs have kept rising ever since rather than going down. So, one must say, this new DRG system has failed in several regards. Politicians must face that and acknowledge the fact rather than stay in denial. They have to humbly admit that it was a mistake to introduce the DRG’s, a mistake of catastrophic proportions, which eroded the social core of medicine, and even jeopardised the mentality of health care professions. And it destroyed the faith of the public in the social character of the health care system. These are the consequences of the total fixation on economy: the devastating result of lost faith. And therefore we must revise the system. And a little bit of fine-tuning won’t do, we need a new system in which making money has no place in medicine, but only the question how one can help people. I see it every day that this is exactly what my students want to do. They want to help other people. They don’t want to get involved with accounting. Of course, the other extreme of wasting money must be avoided, too, but this is not achieved with the DRG system either, but only with prudent investment in professional medical care, which upholds the value of carefulness, the approach of small and careful steps, rather than doing things for the sake of doing.

But why don’t more medical doctors rally to stand up for these values? Most of them are highly educated, they have a lobby and especially now – since virologists’ expertise in particular is in such high demand – their voiced are heard much better?
Yes, this is very, very important question indeed, which in my opinion can only be answered by

  1. acknowledging that medical doctors are divided among themselves and don’t speak with one voice, and that there are many doctors who are winners of the old system. Many doctors have been corrupted by the good salaries they received for just operating. Not all of them suffered. And
  2. medical doctors are not very political in general. Neither are they organised in any bigger political bodies. All they want to do is helping patients, they want to help sick people. As for their main inner compass they are not politically minded persons. And this is their disadvantage right now.

I spoke with Giovanni Maio, medical doctor and philosopher at the Institute of ethics and history of medicine, about a new reimbursement model for our health care system.   •

Source: www.deutschlandfunk.de from 19 April 2020; Transcript Current Concerns;
Reprinted with kind permission of Professor Giovanni Maio and Deutschlandfunk

(Translation Current Concerns)

Professor Dr med. Giovanni Maio studied philosophy and medicine. After many years of internistic-clinical practice, followed by a period as a scientific assistant at medical theory institutes he habilitated in the field of ethics in medicine (July 2000). In 2002 he was appointed to the Central Ethics Committee for Stem Cell Research by the German federal government. In 2004 he had been offered a professorship at the University of Bochum followed by the C4 professorship for medical ethics and history of medicine. In 2004 he has been offered a chair (C4 professorship) for history and ethics of Medicine at Aachen University, in 2005 a professorship at the University of Zurich (Ordinariate for Biomedical Ethics). In 2005 he became the Managing Director of the Interdisciplinary Ehtics Center in Freiburg and since 2006 he is the Director of the Institute for Ethics and History of Medicine. Since 2007 he is an appointed member of the Committee for Ethical and Medical Judicial Basic Policy Issues of the German Medical Association.

In his publications since 1998, Giovanni Maio has been committed to human medicine. In 2018, his book „Werte für die Medizin. Warum die Heilberufe ihre eigene Identität verteidigen müssen“ (Ethic values for medicine. Why the healing professions must defend their own identity) (Munich: Kösel) was published. The second edition of his medical ethics textbook, “Mittelpunkt Mensch. Lehrbuch der Ethik in der Medizin“ (2017)(Centre of Man. Textbook of Ethics in Medicine) contains an introduction to the ethics of care (Stuttgart: Schattauer). In his book “Geschäftsmodell Gesundheit. Wie der Markt die Heilkunst abschafft” (Business Model Health: How the market is abolishing the healing arts), published in 2014, Giovanni Maio describes, among other things, what he means by “relational medicine”.

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