What is the standard of Cancer treatment in Germany?

For international patients who need treatment regarding specific cancer conditions, German clinics offer a wide range of medical treatments and institutions.

For the rather frequent types of cancer, like colon, breast and prostate, the approach is usually a combination of surgery, radiation therapy and chemo-therapy. Hospitals are developing institutions called "centers", which combine the efforts of the different departments and ensure a treatment scheme which is carried out along agreed procedures, based on the consensus of all the faculties that have joined. Regular joint conferences discuss all the patients and define the medical strategy according to the guidelines of evidence-based medicine. A few of these centers, like "breast centers" or "intestine centers" qualify to undergo a special peer review process, for example by an institution called Onkozert, which awards them the label "Certified Center".

In these cases, if the condition is diagnosed early enough, the chances of completely curing the disease are frequently very good.

For the more rare types of the disease, special units in the big university hospitals have been established, where, for example, bone marrow transplants or special neuro-surgical operation techniques like the "Gamma knife" are a regular mode of treatment. Other clinics provide hypothermia treatment, special laser treatments for liver metastases or any other up-to-date therapy.

For all these big centers it is important to know, that they participate in the research for new cancer treatments by taking part in studies. So, if the patient agrees, it is possible to benefit from the latest developments, especially on the cancer drug sector.

Before this background, with the help of a qualified referral organisation like German Hospital Service Ltd., patients can be sure to find the best possible treatment for their cancer condition.

However, it must be understood. Even the best treatment procedure cannot promise to provide a cure to a cancer patient.

Especially, when the treatment starts too late, doctors will only be able to prolong the lifespan of the patient, while improving the conditions of life during that final stage.

Is it a good idea to plan the birth of your child in a German hospital?

For any hospital in the world, the obstetrics department is one of the very important clinics. Not because the medical challenges are so great, but because here the “clients” are not really sick, and usually the outcome is a happy one. Under marketing aspects, this is ideal for establishing a new client relationship which can, if the parents are happy with the treatment they received during the birth of their child, lead to a life-long relationship, even including the rest of the family.

German hospital managers have understood this very well. So most have spent substantial amounts to make these parts of their hospitals most attractive: Beautiful rooms with modern, family-oriented furniture at good hotel standard, special buffet style breakfast for the mother AND the father (who can also share the room with her, and stay overnight). Specially designed delivery rooms with all the equipment imaginable for any delivery method the mother could wish: big round beds, underwater- delivery tubs, supports and chairs, together with soft soothing music, special light effects, storage of all medical machinery out of sight make these “birth rooms” feel more like comfortable living rooms that anything else. And Fathers are really welcome to join their partners during these important hours; many clinics permit them even in the operating theatre during caesarean birth. Of course, medical standards like online monitoring of the pre-birth parameters of mother and child, all known methods of pain relief/suppression, the availability of a special operating theatre with surgery team in case of need (e.g. of a casarean birth) are ensured – but not in the foreground. Everything is focused on making the birth of their child the most emotional positive experience for the parents.

Some links showing beautiful clinic examples:

http://www.ukb.uni-bonn.de/42256BC8002AF3E7/vwWebPagesByID/64485F60B46B5750C1256E4B0057541B

http://www.vincentius-kliniken.de/vincentius/export/pics/kliniken/gyn/wanne.jpg

http://www.maerkische-kliniken.de/Klinikum/Kliniken_und_Institute/Fachabteilungen/Frauenklinik/DGeburtshilfe/Geburtshilfe.htm

http://www.klinikum-barnim.de/klinik_frauenheil

Due to this competition among hospitals, parents-to-be have developed the habit of travelling around to visit the various providers in their area, look at the facilities, speak to the doctors and the midwives, and then decide, where they want to go for giving birth.

Some additional aspects are also relevant for this “clinic shopping”: Is the doctor a specialist in pre-natal diagnostics? How high is the rate of caesarean vs. natural delivery? Does the hospital try to promote breast feeding or not? Are the midwives freelance or employed by the hospital? Is the doctor in private practice or hospital resident? Does the clinic have a quality certificate like KTQ, ProCumCert? Is there a paediatric clinic available in the same hospital? Does it provide care for prematurely-born babies?

One important criterium: How many births does the clinic have per year? German regulations have a tendency to restrict the license for obstetrical care to clinics that have more than 300 births, although the medical evidence, that this is really a valid quality benchmark, is under debate.

Luckily, in most cases, all this is not really necessary. But the main reason for going to a hospital for delivery (and not go to a “Geburtshaus” run only by midwives or stay at home and having “your” midwife come to your home) is that parents look for the extra safety, which easy availability of all the hospital staff and facilities gives them for any emergencies.

For international patients who consider coming to Germany for the “Big Day” all these criteria also apply. Referral organisations like German Hospital Service Ltd. will assist them to get the relevant information ahead of time.

But of course one little problem remains: The exact date of delivery cannot be planned. So the best you can do, is to travel to the city with the hospital you have chosen, ahead of time, and plan to stay at a nearby hotel until labour gets under way.

By the way: Under German law, a baby does not acquire the German nationality by being born there. So this would not be an argument for coming to Germany for the birth of your child. But the excellent medical standard, together with the special attention that hospitals offer to delivering mothers and their families can be a perfect reason.

Is language an issue for international patients in German hospitals?

Language can be an issue - especially if it is not English.

While it is fair to say, that just about all German physicians will be able to communicate very well with patients in English - even to the point of having psychotherapeutic sessions - this will not be generally true for the other hospital staff. Nurses and administrators ususally have a training, which has not emphasized the command of foreign languages.

And in our experience, also for the physicians there can be a problem when it comes to written communications, reports etc. Of course in the big university clinics, where the medical staff is also involved in research, which includes presenting papers to the international science community, this will not be an issue. But at smaller hospitals it might take a little longer to get a report in English.

Other languages will be definitely less common, with two exceptions: Now-a-days, many physicians from the Eastern European countries can be found in German hospitals, so there will be a fair chance to find someone who can speak Russian in most hospitals - frequently also among the nursing staff. And there is a strong tradition of physicians from arab-speaking countries like Iraq, Iran, Lebanon to spend at least part of their training in Germany - and many stay. So Arabic will also be availabe in most hospitals, though not in every department.

In effect, with one of these three languages, German Hospital Service Ltd. will be able to find a hospital where an international patient will be welcomed to his understanding.

Which quality management systems are used in German Hospitals?

German hospital legislation requires all hospitals to adopt „a quality management system”, but there is no regulation as to which system should be used.

Consequently, almost all the possible QM-systems and certifications have their customers: The JCC (joint commission certificate), the DIN-ISO 2000 etc., the European quality award EFQM and two specific systems, which were developed by the hospital scene together with the social security health insurance, KTQ (Kooperation fuer Transparenz und Qualität) and ProCumCert. These systems all have in common, that the general procedures for important activities have to be written down, followed and evaluated. In addition, factors like patient and staff satisfaction, financial solidity and leadership are important – though the weight differs between the systems. The PCC-certification was created for the many hospitals under church responsibility; here aspects of spirituality and religious orientation are additional criteria.

Over all, it is to my knowledge fair to say that KTQ and KTQplusPCC have the largest part of the certification market.

In addition, there is an increasing number of specialized certificates: Breast centers (mammary oncology), intestine centers (intestinal oncology) and others are certified by an institution called Onkozert; efforts in favour of breast-feeding are certified with a family-orientation certificate by the WHO; the WHO-initiative called health-promoting hospitals makes for an increasing network, also the initiative for smoker-free hospitals with 3 different levels of certification. Special institutions within hospitals again have their special QM-certifications: laboratories (DAR), radiology (governmental radiation control) etc.

Of course all these systems and procedures of quality management are focussed on the aspects of structural quality and procedural quality. Outcome quality is hardly an issue in these systems. And, of course, a measurement of outcome quality, moreover in benchmark comparison with other hospitals, is a difficult issue. Some hospitals have started to address it cautiously, by including additional data in their annual quality reports.

These reports are also required by law every two years and have to be published on the internet. They provide information on the hospital’s infrastructure, the most frequent medical procedures and also on the quality management system that is adopted by the hospital. On a voluntary basis, some hospitals also publish statistics like mortality rates, infection rates etc..

Two more quality management aspects should be mentioned:

For certain procedures a special government institution has published minimum quantity standards regarding the number of procedures per year. For example: A hospital, that has not performed a minimum of 50 total knee implant operations in one year looses the permission to continue offering this type of service.

And for an also increasing number of medical procedures hospitals have to provide a host of medical data to the central medical councils. These data are studied by special committees of physicians, and clinics or departments with big deviations from the standard are faced with critical reports that call for measures to improve the situation. But up to now, also because the criteria are very medical and their relevance is not always obvious to a layman, these reports are not available to the public yet.

What is the situation regarding legal liability for medical treatment in Germany?

Regarding the liability for any medical treatment activity, we have to look separately at what kind of claims could be raised.

• Claims for unsatisfactory results of treatment. ( "I spent a lot of money on the doctor and the hospital, but all their activities were to no avail. My cancer disease was not cured - or my left breast is still smaller than the right one.")
  For such claims, the legal system in Germany offers no legal grounds. The treatment contract, which is made between the hospital (or the doctor) and the patient does not entitle the patient to any guaranteed results. The contract only obliges the hospital or the doctor, to treat the patient according to up-to-date medical standards. But there will never be any contractual obligation to ensure a certain result.
• Claims for personal injury. As medical treatment is administered mostly by human beings, it is never possible to exclude the risk of any mistakes happening during treatment. A mistake could be, that the operation team forgets a medical instrument inside the patient' s body, or that the nurse gets the medication for patients mixed up, and causes serious health problems to a patient. Also, if the treatment was not given according to the state of the art, or a necessary diagnostic procedure was forgotten, that would be considered a mistake.
  For such cases, the legal system in Germany provides a number of claim possibilities. However, the claimant has to prove that a mistake was made, and that someone is personally liable for this mistakeL Liability can be based on intent or negligence, and even slight negligence can lead to full personal liability for all the financial damages that arise from the mistake. In principle, the claimant can demand to be restituted into a position as if the mistake had not occured (i. e. repair of damages). If that is not possible (e.g. the wrong leg was amputated), the financial consequences (treatment costs, reduced ability to work etc) have to be covered.
  However, the German system focusses more on the material damages. Immaterial damages, like compensation for pain, shock or emotional distress, are not considered as important and the sums of money which are awarded by courts for these reasons are low compared to, for example the United States.

For both types of liability, the hospitals and their doctors of course have their liabilty insurances. So the claims are not really dealt with by the hospital. The insurance companies decide, when they admit liability and offer payments or when they seek justice by court decision. And here also, there is a noteable difference to the situation in Germany: Most civil liability cases are really decided by the courts, and negotiated settlements are less frequent.

Is there a tax on hospital invoices which international patients can get refunded?

This is a question, that has been posed a number of times. The answer is: Generally not.
The fact is: For normal medical treatment there is a general exemption from the VAT (Value added tax), for non-profit hospitals (the vast majority of hospitals) as well as for private clinics. Medical services, at least as long as they are medically necessary, can be invoiced without VAT; consequently there is nothing to get refunded when the patient returns home.
By the way: The same applies for doctor's fees: Doctors do not qualify for VAT invoicing for medical services they provide.
Only in such cases, where no medical need whatsoever can be shown, for example plastic surgery for purely aesthetic reasons, this service will be considered to be simply commercial, and the VAT has to be added on the bill. And even in such cases, if the hospital normally has only medical treatment patients, the VAT will often be forgotten by the administration (how should they know, that there are no medical reasons for the treatment in this specific case?)
But of course, if a private clinic has specialized on such operations, or if a doctor also sells goods (like a special machine or drug) they will be in the focus of tax authorities and will add the VAT routinely.
But that will be a rare exception.

Is it possible to have major transplant surgery as an international patient in Germany?

It is not the most frequent type of medical problem which international patients look to get treated in Germany - but kidney transplants, lung transplants, liver transplants etc. are definitely among the desired treatments, which patient referral organisations like German Hospital Service Ltd., encounter among their patient requests.
And why not? A number of highly qualified transplant centers, usually in the big university clinics, perform these high-tech operations regularly and have a lot of experience. So why should international patients, who perhaps do not have these facilities in their countries, not profit from this expertise.
Right! They should, and in principle they can. With one big BUT: They need to bring their own live donor, if they need a live transplant. Why?
In Germany, like in most countries in the world, the demand for organs greatly exeeds the avilable donations. And although a europe-wide organisation, EuroTransplant, tries to coordinate the exchange by maintaining a huge data base of patients who are waiting for an organ and comparing the medical parameters of every organ that can be secured from accident victims etc., in many cases the wait on the list can be too long, and patients will not survive long enough for a suitable organ to be found.
Due to this grave shortage, it has been decided, that only patients who are residents of the EuroTransplant countries, can be eligible for the waiting list.
This means, that an international patient can only be considered for transplant surgery, if he has a relative or close friend who is willing to donate, for example, one of his kidneys to him. And in Germany, like in most other European countries, the donation of organs for financial considerations is considerd unethical and illegal. Every single case of voluntary donation is closely examined by an ethics committee before the permission for the transplant operation is granted.
So: While is may not be major problem in some countries to "buy an organ", it will not be possible to bring such a donor to a German hospital and have get the desired surgery.
Only if the donor is really a member of the family, and if it can be shown that the donor acts of his own free will and not under any pressure, the ethics committee will allow the doctors to begin the treatment.