File transfers

One of the important things about getting a treatment referral is that the patient can provide as much information about her/his medical condition. While letters and other written documents can of course be scanned and sent by email, this is not feasible for big files like y-ray pictures, CT- or MRI scans.
In times of cloud computing, it is a good alternative to get some free cloud storage, like Goggle-Drive to store medical records. These can then be shared by emailing the links only.
German Hospital Service is using multiple cloud storage providers. To facilitate data management by accessing all these accounts and shifting files between them, we have decided to use a specific tool which we find very useful:
MultCloud(https://www.multcloud.com/), a FREE and easy-to-use web app, supports for Managing Files and Transferring Files across Cloud Drives. Free provide 10TB traffic for data transmission.

New translation services launched

In order to facilitate patient referrals to Germany, we have often been asked for translations. This gave us the idea to start a new web-based translation and language service: www.languages4you.eu. For our three primary languages German - www.deutsch.languages4you.eu -, English - www.english.languages4you.eu - and Russian - www.russki.languages4you.eu - we offer translation of medical and other documents at fair prices and a host of other language services, such as interpreter facilitation of Skype calls, proofreading of scientific and other materials, tutoring and Skype based languuage course. So for any language services in German, English or Russian, please check our site. www.languages4you.eu.

Ion-Beam Cancer Therapy, Germany on the Forefront

Treatment of most cancer patients has three components: First the surgical intervention to try an remove the malignant cells, second chemotherapy with aggressive medication to try and eradicate any left-over cancer cells from the body and, third or simultaneously, radiation therapy to kill cancer cells that could not be removed by surgery.
For this radiation therapy, the standard is a focussed and carefully planned application of Gamma or X-rays, radiation that is well known to damage body cells nearly since Conrad Roentgen.
Medical technology has however developed new therapies using other radiation forms. Worldwide, also in Germany, proton radiation has been introduced and found beneficial for many patients with different cancers / types of tumors. The advantage is that the radiated particles are bigger (protons), thus the damage they can cause to the tissue thay are targeted on is more severe. However, the machinery needed to radiate protons are bigger, more sophisticated and more energy consuming than standard gamma-ray machines, consequently only few, big centers have been built and are available for patients.
Along these lines, but with still bigger particles, still bigger and more expensive machines, Ion-Beam Radiation has been developed in recent years and established - up to now at three centers worldwide. Here, heavy ions (carbon) are used to bombard the tumour cells and destroy them. One of these centers is the Heidelberg Ion-Beam Therapy (HIT) Center, associated to the Heidelberg University Hospital and to the German Cancer Research Center, also Heidelberg.
HIT has been chosen as the national reference center for clinical studies on the use of ion beams in cancer treatment, and of course it is also in constant exchange with colleagues at the other centers in Japan and Italy. 
HIT claims to have the following special features:

• The world’s first ion therapy facility with intensity-modulated raster scanning, the world’s most precise radiotherapy method.
• The world’s first heavy ion treatment facility with a 360° rotating beam delivery system (gantry).
• Europe’s first combined treatment facility using protons and heavy ions for radiation therapy.
• The first facility to use cooperating robots for automated imaging and ultrahigh-precision patient positioning.

Patients who are thought to benefit most from this treatment are those who have tumours

• that are located deep inside the body,
• that are extremely resistant to conventional radiation,
• that are surrounded by highly radiation-sensitive healthy tissue, such as the optic nerve or bowel, which should not be damaged during treatment.

Treatments at HIT are still at the level of clinical trials and studies, but it has been shown already that in most cases, the success rate of Heavy Ion Radiation nears 90%, whereas other forms, including proton radiation has rates up to 70%. So it is estimated that in the long run, this therapy could be beneficial for about 10% of all cancer patients.

The costs of such treatments are high, about three times the cost of conventional radiation therapy. However, the center has contracted to get coverage of these costs by most German statutory health insurance companies. Patients who do not have this coverage will have to pay privately, unless they can obtain coverage from their private health insurance. There is no exclusion of international patients.

German Hospital Service will be more than happy to help international patients establish contact to the HIT center. Medical evaluation will be done by the center to ensure that the patient is a good candidate for one of the study programs. Then, a cost estimate can obtained so the patient can decide.

Help for Glaucoma Impaired Vision?

One of the most frequent causes for partial blindness is glaucoma. Ophtalmologists tell their patients, that the situation, once it has developed, cannot be cured or improved. The reason for this verdict is, that patial glaucoma blindness is caused by damage to the optical nerve - nervus opticus - and current medical standards maintain that nerve damage cannot be repaired.
There is, however, increasing evidence that this view is too harsh. Neuronal plasticity is the word, implying that in the nervous system there is certain ability to repair damage, not making total restitution possible but showing improvement of residual eyesight. And such improvements are possible even many years after the damage occured.
It is a German researcher, Prof. Sabel, who has been exploring ways to utilize neuronal plasticity to rehabilitate the optical system after damage, due to stroke, glaucoma and other causes, for many years. In 2011, he associated a Russian researcher to his group, Dr. Anton Fedorov, who had been working on the use of electro-stimuli for various therpeutic purposes in Russia, and a new treatment scheme was developed. First published results looked promising -
The author of this blog has been following these developments for years and decided to give the new treatment a try in October 2013. A left eye with about 20% residual eyesight after glaucoma has been troubling him since 2008.
One treatment cycle with Prof. Sabel and the method called noninvasive repetitive transorbital alternating current stimulation (rtACS), takes 10 working days, every there is a session of about 30 minutes on the micro-electric stimulus machine, extensive diagnostics before and after the cycle is done to document the initial status and the immediate results.
However, it is made very clear that the treatment concept is a rehabilition treatment, based on the general idea that rehabilitation after many kinds of damage to limbs and/or nerves usually relies on stimulus and training to regain functionality. Equally, rtACS treated patients are encouraged to continue daily training routines for the eye in order to stabilaze and enhance the treatment results.

Before treatment

After treatment

And what are these results? Well, in terms of measurable effects, the author has only achieved modest improvements. 

In anterior diagnostics he managed to see 25% of the light spots appearing in the perimeter test, posterior results were around 29%. Yet, there are definitely new areas where some partial vison seems to be returning, and at the subjective level clear improvements are observed, although not really in the areas which show improvements in the test..

Conclusion: The rtACS method is definitely able to initiate a process of improvement, especially where there is some residual sight to stimulate. Micacles, in the sense of curing blindness, are not possible and not to be expected. But if, like in the author’s case, there is a return of some sight in the lower part of the visual field, that can be a very important result already: You can see, where you are going!
Based on this experience, German Hospital Service will be more than willing to help interested international patients to profit from this novel treatment. There are considerable waiting lists at Prof. Sabel’s Institute already.

Regional deep hyperthermia could be a treatment for children and adolescents with refractory or recurrent non-testicular malignant germ-cell tumours

Medical researchers at the Paediatric Oncology Clinic, Haematology and Immunology, Centre for Child and Adolescent Health, Medical Faculty, Heinrich- Heine-University Düsseldorf, Düsseldorf, Germany have recently published findings about a study involving 44 patients, aged 7 months to 21 years, where regional deep hypothermia was successfully used to treat malignant germ cell tumours.

In recent years, the survival of children and adolescents with malignant germ-cell tumours has improved substantially. However, the outcome remains poor for patients with refractory or recurrent malignant germ-cell tumours. The Düsseldorf researchers could show that PEI-regional deep hyperthermia can achieve objective tumour response in a study that followed the patients over more than 7 years after treatment. (The median follow-up of surviving patients was 82 months (range 9—195)).

“Of the 35 patients who had sufficient clinical and radiographical data available for response assessment, 30 (86%) had an objective response to treatment (16 patients had complete remission and 14 had partial remission).” However, granulocytopenic fever, which required intercurrent hospital admission, was noted in 29 (66%) of 44 patients and five patients experienced treatment-related grade-3 acute renal toxic effects.

Nevertheless, researchers conclude: “A multimodal strategy integrating PEI-regional deep hyperthermia and tumour resection with or without radiation can successfully treat children and adolescents with refractory or recurrent malignant non-testicular germ-cell tumours. The long-term prognosis of patients with poor response or after first relapse was almost similar to those receiving first-line treatment. This strategy merits further investigation.”

Obviously, this treatment is still in a study phase and not available as standard treatment. But the results are promising and show the high level of expertise regarding child oncology at this big university hospital. German Hospital Service will be happy to assist international patients if they need treatment in Germany for such severe conditions.

Citation:
The Lancet. July 1, 2013
Dr Rüdiger Wessalowski MD , Prof Dominik T. Schneider MD et al
http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045%2813%2970271-7/fulltext

Do you have to pay VAT on hospital bills?

Recently, this was a question we got from Australia. It appears that a number of patients were being treated in a hospital in Germany, and required to pay the official VAT rate of 19% on top of already high treatment bills.

German VAT is regulated ina law called "Umsatzsteuergesetz". Unfortunately the text is not available in English. Let us try to sumarize what it says about VAT and health care. There is a specific § 4 listing all exceptions to the rule that VAT has to be paid on all deliveries and services in Germany. Here, in section 14, it says:

• Treatments in human medicine, provided by physicians, dentists, practitioners, physiotherapists, midwwives or similar provideers of medical care is exempt.
• Hospital treatments and medical activities by physicians including diagnostics, anamnestics, prevention, rehabilitation, obstetrics and hospice services including all activities closely related to such treatments, if the are delivered by public institutions (institutions governed by public law) are exempt of VAT.
• This exemption is extended to all services delieverd by hospitals and health care centers that have an official accreditaion to serve social security patients, if the services are such as provided under the social security act.

So: Is it possible that you have to pay VAT on hospital services? Yes, but only if you opt to get treatment by an institution that is not affiliated to or accredited for the treatment of patients covered by social security.

As has been pointed out elsewhere, there are basically two definitions of a hospital in Germany. One is in business law, where § 30 Gewerbeordnung requires that anybody who wants run a private health care institution has to have a concession to do so (like the concession to run a bar.) And the second one is in § 108 of Book 5 of the social security act, where the requirements for participating in the provision of hospital services to social security patients are defined.

There is an increasing number of health care providers in Germany who opt out of the social security system, or are not accredited because they provide services which are not within the scope of social sercurity coverage. These institutions are entitled to call themselves hospitals if they have the concession under business law. But their services are not exempt from VAT, so patients have to pay additional 19% (currently).

German Hospital Service will generally not advise customers to consult such institutions as normally there is no need to go there. High level medical treatment can always be obtained by the fully accredited hospitals and most of the really high class institutions are “goverened by public law” anyway: They are the university clinics, universities in Germany being predominantly public institutions.

Successfull transplantation of two arms

Plastic surgeons at a major hospital in Munich, Germany, have presented a patient to the public who had successfully recieved two complete arm tranplants (taken from a deceased donor) more than two months ago and who has been able to overcome repulsion of the new limbs since then.


The patient, who had lost both arms right below the shoulders due to an accident, had recieved the limbs in a highly complex plastic and neurosurgical operation, and over the ensuing months had been administered decreasing doses of immune-supppressive medication. He was also able accept the implanted limbs as his own, which is an important psychological prerequisite for the success of the treatment.


The most important development however still is to come: While the young man claims that he is feeling some tingling in the new arms, there is still no feeling or possibility to control in the implants. The tingling sensation shows however, according to the physicians, that the nerves have started to grow from the shoulders into the strange tissue. It is expected that it will take another one or two years until the patient will regain some feeling in the fingertips and even the possibility to move his hands.


It was the first time worldwide, that a transplantation of two complete arms has been tried and doctors are very satisfied with the outcome so far. Both the surgical and the immune-therapeutical problems have been mastered very well, and even the psychological assistance has successfull.


This new development in medicine shows the high standard of medical service that is available in Germany. While such sensational transplantations are still far from available on a routine basis, medical development does of course make novel treatments possible - also to international patients. Patient referral organisations like German Hospital Service will be happy to assist.

University Clinic Magdeburg introduces World Innovation for Cancer Therapy

In January 2008, a medical team at the Magdeburg University clinic was the first worldwide to introduce an open, high energy MRI for micro-therapeutic oncological treatment techniques. The new MRI, which does away with the classic „MRI-tunnel“, gives the doctors free access to the patient, enabling picture-controlled interventions to bring micro-invasive instruments right into the tumors, providing excellent picture quality without x-ray exposition for the patient.

Modern cancer therapies are often very hard on the patients – physically and psychologically. Extensive surgery weakens the body and leads to long periods of recuperation. The new therapeutic approach, with micro-invasive instruments, is usually possible under local anaesthesia only, while these instruments bring the treatment into the centre of the cancerous tissue. Right there, from “within”, the tumor can be subjected to radiation or microwave heat, targeting the cancer tissue only but leaving the healthy surrounding organs untouched.

Hitherto, ultrasound or CT were used to guide such interventions. But according to the doctors at Magdeburg, the new MRI is far superior: This technique is specialized on making soft tissue visible, while X-ray based pictures are more or less confined to bones and similar calcium-containing structures. And the open design of the new machine enables the doctor to apply his instruments directly and under full control of high quality online pictures.

For the Magdeburg clinic, this is a „milestone in micro-invasive oncology”.

The city of Magdeburg is in the immediate vicinity of German Hospital Service, who will be happy to assist international patients if they wish to apply for this new treatment option.

German hospital pioneers intra-womb surgery

The university hospital Bonn saved the life of a baby by applying an innovative technique for antenatal surgery in womb.

When her mother's foetal membrane burst in the 20th week of pregnancy, there was immediate danger that the baby Miriam would die, as his liquid cushion is usually absolutely essential for survival of the foetus.

Without the fluid, the organs pressed on the lung and the baby's development would have been fatally impaired. She was also unprotected against germs in the womb, leaving her susceptible to life-threatening infection.

Most babies are aborted after a rupture at such an early stage, but Miriam's parents jumped at the chance after the hospital offered them what is normally high-risk pre-natal surgery.

'But here we were dealing with a healthy child and it was a question of significantly increasing its chances of survival,' said Professor Thomas Kohl, the head of the German Centre of Foetal Surgery and Minimally Invasive Therapy at Bonn University Clinic.

Surgeons inserted the operating device, which is the size of a ballpoint pen, into the foetal membranes through a small opening in the stomach of Miriam's mother Lori.

Assisted by a camera and ultrasonic apparatus, they carefully moved this 'foetoscope' via the mouth and into the trachea of the unborn baby.

There a miniature latex balloon was inflated, blocking the respiratory channel so that the fluid which is continuously produced by the prenatal lung cannot drain away. This build-up of the fluid stimulated the growth of Miriam's lung.

Miriam's case was the first in which Professor Kohl also used the protein serum albumin, which increases the amount of water collected in the lung and increases the effect of the balloon.

'Our little patient's lungs rose like yeast cake. The balloon stayed in the lungs for five days and during this period the volume of the lungs nearly doubled,' said Professor Kohl.

Miriam was born in the 33rd week of the pregnancy and is now a healthy one-year-old.

The operation that saved her life was to be reported in the scientific journal Fetal Diagnosis and Therapy.

This AFP-Report is brought to you by German Hospital Service to describe the high level of expertise that can be found in german hospitals.

Fertility Treatment in Germany

Assisting couples to have babies is a very popular medical activity in Germany!

Starting in the beginning of the 90ies, reproductive medicine has gained increasing attention in the medical scene in Germany. Today, there are well over 100 fertility centres in Germany. While they are usually concentrated in bigger cities, it is also possible to find very qualified teams in medium size towns. Gynaecologists and specialists in reproductive medicine offer the full spectrum of up to date diagnostic and treatment strategies, often in close cooperation with other specialists, like urologists.

• Menstrual cycle monitoring and diagnosis
• Diagnostics
• Investigation of fallopian tube functioning and patency (endoscopy, contrast ultrasound)
• Investigation (spermiogram) and treatment of male fertility disorders, andrology, urology
• Hormonal diagnosis of all male and female sterility-related factors
• Human genetics
• Immunological diagnosis and treatment
• Polar body diagnosis (PBD)
• Diagnosis of trace elements, harmful substances and allergies
• 
  
• Treatment techniques
• Endoscopic treatment/operation of any disorders relevant to fertility (adhesions, endometriosis, myoma, uterine septum, etc.)
• Homologous insemination (IUI)
• Hormone treatment in follicle ripening disorders
• In-vitro fertilisation/embryo transfer (IVF/ET)
• Treating desire for children in patients with transverse spinal cord syndrome / paraplegia
• Cryoconservation of gametes (sperm and egg cells) and fertilised oocytes
• MESA/TESE (epididymal / testicular sperm extraction)
• Microsurgical refertilisation, particularly after tubal sterilisation
• Intracytoplasmic sperm injection (ICSI)
• Special strategies for high risk pregnancies
• Nutritional counselling
• Psychological counselling
• Support groups: therapeutic one-to-one and group counselling on the topic of desire for children
• Acupuncture as assisting therapy

Fertility centers are almost always organized on outpatient basiss, though they usually have a day clinic where patients can rest after strenuous procedures. However, as especially international patients will be advised to stay around for a number of weeks, the centers will cooperate with appropriate and attractive hospitals.
Fertility assistance is a medical area, where the general health insurance system in Germany generally will not cover the costs. So in this field, patients will usually have to pay the treatments privately. This has lead to substantial quality competion between the centers, and they have developed high levels of patient and service orientation aswell as attractive architectural ambiance.

International patients will profit from this and feel very welcome. Of course German Hospital Service Ltd. will be very happy to assist you to find the best center for your needs,

What a foreigner should know about hospital and doctor’s bills in Germany

Treatment in hospitals and private practices of physicians is never free. Someone will always have to pay – and as foreigners are usually not covered by social security health insurance (which is compulsory for the majority of German citizens) this will usually be the patient. (If he has private insurance coverage, he can claim reimbursement afterwards.)

For outpatient treatment in private practice, there is a special government-regulated price list called GOÄ –Gebührenordnung für Ärzte. Here, prices for most of the activities and procedures that can happen during diagnostics and treatment, are fixed. Rather, to be more exact, a baseline price is fixed, for example for a normal consultation (also by phone), the price is 4.66 Euro. This basic price can, legally, however be multiplied by a factor of up to 3.5, if the activity was more complicated than usual, or if the doctor has agreed beforehand with the patient, that a certain multiplication factor will be applicable. So, for every visit to the physician, there should be a detailed bill which shows all the activities which where done – sometimes it is worth checking whether you can remember that all those procedures shown on that list really took place. Increasingly often, the insurance companies also check the bills and sometimes dispute critical items.

The same procedure will also be applied when the medical activity took place in a hospital on inpatient basis, if the physician has concluded a treatment contract with the patient to this effect. Such contracts are possible

• Firstly, if the physician is employed by the hospital, and the hospital has granted him the right to treat and invoice private patients – a privilege which is usually given to senior consultants or department chairmen only (for these, it is simply part of the salary deal).
• Secondly, the “Belegärzte”, physicians in private practice who have a contract with a hospital that they may treat inpatients there, will write a separate bill for their efforts. In both cases, these bills will come on top of the hospital bill.
• And if more than one physician was involved in the treatment process (e.g. cardiologist, surgeon, radiologist), each of these will present his separate bill for his activities.

Here also, the GOÄ is applicable; here also, the multiplication factors can be effective. One important aspect is: The patient is entitled to personal treatment by the physician himself, delegation to subordinate physicians is legally correct only under very restricted circumstances.

The hospital system for calculating the invoice, is another, and rather complicated process: First, based on the prevailing diagnoses and the procedures that where done, a DRG will be defined. The DRGs (Diagnosis Related Groups) are published by a governmental agency every year, the list comprises more than 900 different case rates (Fallpauschalen). For example, the DRG I78Z would be coded for the treatment of simple injuries of the shoulder, arm or leg without any complications; I44B would describe the implantation of a knee prosthesis without complications. Each of these DRGs is associated with an exact case value (for I78Z it would be a value of 0.411, for I44B the value is 2.600 in the 2007 catalogue). This DRG-value is then multiplied by the base rate of the individual hospital for the current year, which is the result of yearly negotiations of the hospital with the health insurance companies. Most base rates will be in the range of 2600.- to 2900.-Euro. So, for the activity described by I44B, the hospital bill would be 7280.- Euro if its current base rate is 2800.-Euro. All hospitals are obliged to inform patients about this system and the currently applicable base rate prior to concluding the treatment contract. There can be other, additional rates for special activities or very expensive materials, but usually these DRG prices also include the costs of implant materials, expensive pharmaceuticals etc.

The important point is now, that the DRG bill also includes the costs of medical staff, i.e. the physicians. And for social security patients, this price will be the complete cost of treatment. However, if a patient has decided to opt for private medical treatment by the senior consultant or chairman of the department, this personal treatment bill (as described above) will come on top of the DRG bill, and the patient (or his insurance company if he has coverage for that) will be responsible for both bills. The basis for such dual billing must be a dual treatment contract, which means: If, and only if, the patient has signed the additional contract for the individual medical treatment, the doctor will be entitled to the payment of his separate bill. And the interesting part: There is no obligation at all, for any patient whatsoever, to contract for this additional, optional private treatment! It is your right as a foreigner with or without insurance coverage to decline this option and go for standard medical treatment. The medical standard of your treatment will not be really different, as the doctors who will treat you are under the supervision of the same chairman who offered personal treatment. All you have to do is decline the additional contract when signing the hospital admission contract papers, and the hospital staff is not allowed to pressurize you to sign the private treatment contract as well.

And one more point: While it is true, that the DRG System is mandatory for social security patients, that does not give the hospitals complete freedom to leave this system for foreign or other private patients. There is also a rule which prohibits that hospitals make different prices for different groups of patients. So only private clinics which have no social security contract, may devise their own pricing system.

The same is incidentally true for the other optional features, like single room privacy or accommodation in a 2-patient room. Here also, the patient is free to decide whether he wants to sign for the additional options, no coercion is permitted and only the prices which are published by the hospital for all patients may be applied.

All this tells you: While there is a lot of regulation about what is permitted in terms of doctor’s or hospital billing, there is also a big range for optional agreements. And it is up to the patient, which options he contracts, sometimes substantially increasing the costs of treatment.

Also: The assistance by a patient referral organisation like German Hospital Service Ltd, can be very valuable: During the admission process and after the treatment, when someone with the relevant know-how can check the bills to make sure that there are no mistakes.

Endoprosthetic Surgery Treatment in Germany

Artificial knee prosthesis, partial or total hip prosthesis can be considered standard treatment options in most clinics specializing on orthopaedics or casualty surgery in Germany. Other specialties, which are only offered by a few clinics, are artificial discs to return or maintain full functionality of the spine, or replacement surgery in the elbow or shoulder.

All these treatments are of interest to international patients for a number of reasons:

• The quality can be good to excellent because of high level of expertise and competition between hospitals
• Even patients at high ages can be offered these treatments, as the surgical management is highly sophisticated and tolerable even for frail constitutions
• The costs, while probably not cheap by international standards, are reasonable, and the implant materials will be of excellent quality. The cost estimates which hospitals will give prior to such operations are usually very reliable, as the procedure is well under control.
• For standard procedures international patients will not face any waiting lists: Every patient is welcome.
• Some of the more advanced treatments are not available in some other countries, or only since a very short time, while in Germany there is a lot of experience already. An example for this is ADR: Artificial disc replacement, which was established in Germany years ago.

When choosing the clinic for your treatment, there are some considerations to keep in mind:

• How far developed is the experience with your required procedure? For some treatments, like artificial knee implantation, a quality regulation is in force which requires, that a clinic must perform at least 300 of these operations per year in order to be permitted to continue offering them. For other procedures, it might make sense to study the quality report which each hospital has to provide, and which can be researched via internet.
• What is the qualification of the responsible physician? Is he an orthopaedic surgeon, a casualty surgeon or has he got the new certificate which combines both specialities?
• Well qualified clinicians are licensed to train assistant physicians. The number of years they may offer this training is a good indicator of the quality of the clinic and its medical spectrum.

During the time, when fear of getting blood preserves which might be contaminated in some way, all major clinics have introduced the option of having the patient’s own blood transfused. This means of course, that patients have to attend a number of appointments for blood donation well before the surgery date, in order to accumulate the necessary quantity of blood preserves for his treatment.

One other specialty about the German system should also be mentioned in this context: One branch of the German social security system is compulsory casualty insurance for workplace accidents. These insurance institutions, “Berufsgenossenschaften” run a number if hospitals, where, of course, the main focus is on the treatment of patients after serious accidents. In such a clinic, the surgeons who are responsible for orthopaedic medicine will usually have a lot of experience and a high level of expertise.

All this goes to show, that it is essential to have insider knowledge about the clinics and their specialties. Which is where referral specialists like German Hospital Service Ltd. come in: They can get access to all the relevant information and assist foreigners in their choice to find the best hospital. Important in this regard is, that the referral service is neutral and independent and not associated to certain clinics. German Hospital Service Ltd. is such an absolutely independent service provider.

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.

What are the prices for hospital treatment in Germany?

Since about 5 years, most hospitals in Germany are obliged to follow special government rules for the pricing of their services. A system called DRG (Diagnosis Related Groups) has been installed by law, and must be followed for all patients for whom the costs are covered by social security schemes.

DRGs work as follows: The relevant diagnosis, the medical procedures and any complicating factors that were encountered during the hospital treatment are entered into a special computer programm (called grouper). The system computes a certain relative weight from these factors. (This kind of system is most well known in Australia, from where Germany has adopted it.) So for example the replacement of an old hip endoprothesis without any complications might have a relative weight of 3.027. This factor is multiplied with the so-called base rate for the individual hospital, which is also fixed according to legally defined process and will be in a range between 2600.- and 3000.- Euro. So the DRG-treatment cost in this example would be between 7870.-Euro and 9081.- Euro.

For international patients, some hospitals adopt this system, others use a higher base rate. Some hospitals even abandon the DRG system and calculate their bills on a per day basis: The day can then cost 500.-Euro or more. This is not really within the legal framework, as there is a general rule that treatment prices must be equal for all patients, regardless of their status.

It is important to know, that the DRG price reflects only the hospital costs. If the patient opts to contract for personal treatment by the department chairman, a seperate bill for doctor's services will be added to the hospital bill. These doctor's costs can be between 50% and 100% of the hospital costs.

Further, international patients are usually offered to stay in single-bed rooms. For this add-on, another 40.- to 60.- Euro (or more) per day will be added to the bill. Normal accomodation will be the two-bed room in some hospitals, some hospitals still have 3 or more patients per room. Because international patients often have a different cultural background, accomodation in a single room is advisable. For example, patients from warmer climates (like Arabian countries or Nigeria) will allways find a room cold that is only heated to the normal German standard of 21 °C, and a compromise with a German co-patient will be difficcult.

In some cases, when certain doctors or hospital departments specialize in specific procedures (like artificial spinal disc implantation), they offer all-inclusive rates for these treatments. Of course, they can only do that if the diagnostic information that is made available by the patient prior to the appointment is reasonably complete and up-to-date.

All this makes the pricing situation for international patients rather confusing. It is thus advisable, to employ a patient referral organisation like German Hospital Service Ltd.. They will assist international patients to make the right options regarding treatment and accomodation standards, and they can countercheck the hospital's invoice to make sure it is according to the rules.