Introduction: Germany’s healthcare system is in a state of transition. Medical Care Centers, Health Centers and Clinic Groups dominate the scene in the current healthcare market.

Objectives: The aim of this review paper is to highlight differences and outline potential developments in order to facilitate understanding of the outpatient sector or, to be more accurate, the entire healthcare sector in Germany in all its different facets.

Methodology: The methodology applied to achieve these goals will take the form of compiling a typology and demonstrating the advantages and disadvantages of the different constructs in the healthcare landscape.

Results: Applying a typology logically results in different types being identified. These types are then depicted with their various features. The differences between these types are highly relevant for Health Science.

Conclusions: In the German healthcare system, there is a clearly recognizable tendency towards very large Medical Units and the inpatient sector intruding into the outpatient sector. Clinic Groups are being formed, and there is political support for this.

Keywords: Healthcare system, Health centers, Medical care centers, Clinic groups, Typology, Health science relevance

INTRODUCTION

The following figure shows the typology development according to Kuckartz in relation to the overarching research question (Figure 1):

“What are Typological Differences in Outpatient Care Systems in Germany with Focus on Public Health?”

Explanations of the diagram:

1. Determine the feature space: This is where decisions are made as to which features are relevant for the typology, in accordance with the available data. In the case of this paper, the relevant features are the German healthcare system and specifically outpatient care.
2. Group individual cases and form a typology: This involves classifying the outpatient constructs: MCCs / Hospital MCCs / Clinic Chains / Private Clinics / Health Centers / Group Practices / Single-handed Practices.
3. Detailed description of the typology: The developed types are discussed.
4. Assign the individual cases (mostly people) to the developed types. Classification of the facts in accordance with the discussed types.
5. Analyze interrelationships: In the conclusions, the interrelationships between the typology and Public Health are explained [2,3].

UNDERLYING FACTS

The authors start by listing the underlying facts relating to the different forms of outpatient care in Germany.

Medical Care Centre

Table 1 depicts the main advantages and disadvantages of Medical Care Centers (MCCs)

THE HEALTH CENTRE

Table 2 depicts the main advantages and disadvantages of the Health Center.

THE GROUP PRACTICE

Table 3 depicts the main advantages and disadvantages of the Group Practice.

THE CLINIC

Table 4 depicts the main advantages and disadvantages of the Clinic.

THE SINGLE-HANDED PRACTICE

Table 5 depicts the main advantages and disadvantages of the Single-handed Practice.

TYPOLOGY AND DIMENSIONS

For the development of a typology, it is first necessary to specify the dimensions that are to be investigated, which will then form the basis for identifying the various types. By way of an example, in the next two sub-sections two dimensions are selected from a large number of possible options.

Number of doctors

The number of doctors working in the medical construct frames certain facts, not only in terms of the size of the particular unit.

Legal form

The legal form is selected as the second dimension as a consistent variable of the medical unit.

Typology development

Tables 6-8 below illustrates the typology development process for this paper [1.17].

Three fundamentally different types emerge for the five medical care constructs under investigation. These types are first typologically specified in terms of their size.

RESULTS

Type 1: Small Medical Unit

The first type: Small Medical Unit, which can apply to single-handed and group practices as well as small MCCs-determined by the number of practicing doctors and probably most commonly taking the legal form of GbR.

Type 2: Medium-sized Medical Unit

The second type: Medium-sized Medical Unit, seems to apply to many MCCs, Group Practices and Health Centers. Determined by the number of practicing doctors. The most common legal forms seem to be the GmbH, BAG and Partnership Company.

Type 3: Large Medical Unit

The third type: Large Medical Unit, seems to apply to Clinic Complexes, which can also integrate MCCs, however, or potentially be MCCs in the form of Clinic Group. Here, the only possible legal form is the GmbH.

DISCUSSION

Other authors, like Wigge [18] for this topic only come to two different MCC Types. But also, in this review paper 3 types of medical units emerge. It should be analyzed deeper with various types of criteria. The advantages of MCCs are well known and analyzed, as are the disadvantages. It is important to recognize that MVZs tend to be large units - often in combination with hospitals. This aspect is taken up by Renger & Czirfusz [3]. According to Hulková [5] there are 3 different types of MCCs. Czirfuszová & Steinecker [4] analyze the relationships between the types of MCC and the transaction cost theory. The health center, on the other hand, is a new form of medical-business association [12]. Independence aspects for the doctors are in the foreground here. However, medical centers bill separately [16]. The group practice as a former advantageous model in the legal form of the BAG can have legal disadvantages for doctors in the event of a possible dissolution [13]. One might think that all doors are open to hospitals due to the changes in the healthcare market [14,15]. When large constructs are created (see Type 3), these are a challenge from a legal and organizational point of view. With regard to individual practices (see Type 1), tax aspects (VAT) are in the foreground.

ANALYZE  INTERRELATIONSHIPS/ CONCLUSIONS FOR PUBLIC HEALTH

One aim of Public Health is to optimize medical constructs. In this context the economy must be the focus of the observer. Without economic categories and tools, the problems caused by medical complexes (Large Medical Units) can no longer be mastered.

For the optimization of the units’ side services are considered a potential solution, such as IGeL services (health services not covered by health insurance) or combination offers (naturally depending on size) such as fitness services or new legal constellations such as selective agreements with health insurance companies.

Focus must also be given the aspects of quality in relation to healthcare. The budgeting is seen as one of the main problems by those working at the small medical units, as higher costs (e.g. for investments in equipment) can only be absorbed by higher revenue and this greater profit.

The developmental trend in Germany for the outpatient sector is towards the creation of large management-based units, or Clinic Groups, which is also supported by policy. Accordingly, the outpatient sector is moving away from Single-handed Practices, towards Public Health and even intruding into Hospitals, regardless of the legal form in which the units have been organized in the outpatient sector to date.

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