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Abstract: Aim: To identify effects of ‘needs planning’ for doctors under contract with statutory health insurance in Austria and in Germany on the evenness of doctors’ geographical distribution. Subjects and methods: Based on a description of ‘needs planning’ methods in both countries, the uneven regional distribution of general practitioners (n=59.724), ophthalmologists (n=5.789), otorhinolaryngologists (n=4.326) and urologists (n=2.903) is evaluated at the NUTS-3 level by ascertaining the respective Gini coefficients as well as by presentation of the Lorenz curve and cartographic analysis for ophthalmologists to serve as an example. Results: The regional distribution disparity in all four specialities is less pronounced in Germany than in Austria. This difference can be seen most clearly for ophtalmologists (Gini coefficient 0.166 in Germany, 0.226 in Austria). However, a different result is obtained when ratios in Germany are compared with those of the contract specialists in Austria. In this comparison the regional distribution disparity for the general practitioners and otorhinolaryngologists in Germany is more pronounced than for the equivalent contract specialists in Austria. For ophthalmologists and urologists the situation is reversed, the difference for the urologists being the most striking (Gini coefficient 0.177 in Germany, 0.202 in Austria). Conclusion: Practice planning for contract statutory health insurance doctors in Austria has an effect on the evenness of geographical distribution similar to that of needs planning in Germany. The role of needs planning in promoting an even geographical distribution of office-based doctors in Germany and Austria thus appears clear.

Reorganization of the office-based emergency care system is currently on the political agenda in Germany. Analysing the present situation, the present study makes an empirical comparison between usage of the office-based emergency service and of the competing hospital outpatient departments in different localities, also examining the possible reasons for the differences.

In previous international comparisons of regional differences in the utilisation of selected therapies, individual countries have mostly been described in isolation. In the present study, an attempt is made for the first time to systematically compare the utilisation of selected surgical interventions in Germany and Austria at the small-scale level. Comparative analyses were carried out for three surgical procedures: artificial hip and knee replacements and cardiopulmonary bypass surgery (CPB) using a heart-lung machine.Data were drawn from the German and Austrian diagnosis related groups (DRG) statistics. The regional variation in hospital admission rates was age-standardised and linked to the patients’ domicile before being analysed statistically and cartographically, both as a regional cross-section and as a longitudinal survey. At the county level, the quotients between the highest and the lowest rates in Germany were 2.1 and 3.1 for hip and knee joint replacements respectively, and 2.8 for both in Austria; for CPB interventions the regional variation is somewhat greater, namely 3.7 in Germany and 3.2 in Austria. In recent years, the interquartile distance for the hospital admission rates in individual regions has fluctuated in both countries, so there is no clear indication of a reduction in the regional differences in age-standardised hospital utilisation. The regional variation in selected surgical procedures can be analysed not only within each country separately, but also for Germany and Austria as a single unit, ignoring the border between them.In both countries, the regional cross-sectional analysis at the county level highlights regional distribution patterns whose causes merit further investigation.

Abstract: Aim: When it came into force on 1 January 1993, the Health Structure Act brought about far-reaching changes in the German health system by completely reorganising needs-related planning for office-based medical care. The experience to date suggests that needs-related planning is having an effect. Since the law came into effect, the increase in the number of doctors has clearly levelled off, and in certain fields the trend can even be said to have been reversed. Indeed, needs-related planning will in future have to address a completely new issue, one that only a few years ago was considered inconceivable: a looming lack of doctors. It is precisely in this context that needs-related planning, an arrangement conceived when the number of doctors was rising, can be seen to have strategic flaws. It has now become clear that the data (population, number of doctors) and information on structures (geographical planning units) drawn on in needs-related planning to indicate the degree of provision are unsuitable for ascertaining the need for, and controlling the supply of, office-based medical care. Indeed, the current needs-related planning hardly justifies its name. Subjects and methods: There is a need for genuinely strategic planning that, rather than measuring the status quo in isolation, takes due heed of likely future trends in such factors as population and the number of doctors. Results and conclusion: The reversal of the trend from over- to undersupply of medical care has brought about an increasing scarcity of points of access. If the Associations of Statutory Health Insurance Physicians are to meet their legal commitment to provide universal medical coverage, it is essential that an analysis of the relationships within the care supply network be carried out. A potential solution to this problem is offered by “regional studies interaction models”, which model the physical accessibility and convenience for patients of supplier locations (here: office-based physicians) and the response of the demand side (here: the patients) to the existing geographical constellations.

Abstract: Aim: To identify effects of ‘needs planning’ for doctors under contract with statutory health insurance in Austria and in Germany on the evenness of doctors’ geographical distribution. Subjects and methods: Based on a description of ‘needs planning’ methods in both countries, the uneven regional distribution of general practitioners (n=59.724), ophthalmologists (n=5.789), otorhinolaryngologists (n=4.326) and urologists (n=2.903) is evaluated at the NUTS-3 level by ascertaining the respective Gini coefficients as well as by presentation of the Lorenz curve and cartographic analysis for ophthalmologists to serve as an example. Results: The regional distribution disparity in all four specialities is less pronounced in Germany than in Austria. This difference can be seen most clearly for ophtalmologists (Gini coefficient 0.166 in Germany, 0.226 in Austria). However, a different result is obtained when ratios in Germany are compared with those of the contract specialists in Austria. In this comparison the regional distribution disparity for the general practitioners and otorhinolaryngologists in Germany is more pronounced than for the equivalent contract specialists in Austria. For ophthalmologists and urologists the situation is reversed, the difference for the urologists being the most striking (Gini coefficient 0.177 in Germany, 0.202 in Austria). Conclusion: Practice planning for contract statutory health insurance doctors in Austria has an effect on the evenness of geographical distribution similar to that of needs planning in Germany. The role of needs planning in promoting an even geographical distribution of office-based doctors in Germany and Austria thus appears clear.

This article tests the thesis of supply-induced demand in the German hospital sector. The empirical investigation described makes use of comprehensive data and represents the first time this has been done for Germany. A cross-section analysis is performed at the level of geographical planning regions. At this level the hospital data encompass the whole population and distinguish ten different medical specialities. 13 different economic and social variables are analysed in a system of simultaneous equations. The result shows that the supply of treatment capacity has a positive influence on the demand for hospital treatments, the number of patients treated per 100,000 population rising with bed density. Alternative explanations for this phenomenon are also checked, without result. No correlation can be found between morbidity and the number of hospital cases in any given region. Although hospital bed density is found to depend on the number of hospital cases per head of population, this is no proof of the reverse causality, as this result can be traced back to the strategy behind the existing hospital planning. The validity of Roemer’s Law in Germany is likely to be (at least partially) due to this existing hospital planning. This is because the prevailing hospital planning procedure is distorted, indicating a higher need for hospital beds where bed density is already high. Given this situation, and the results of the regression analysis, it would seem appropriate to consider abolishing the hospital planning system and radically reducing the density of hospital beds.

Dieser Beitrag beschäftigt sich mit der zahlenmäßigen Entwicklung der Ärzte als den zentralen Akteuren im deutschen Gesundheitswesen. Dabei wird zunächst die allgemeine und sektorspezifische Entwicklung der Vergangenheit dargestellt. Die Ärztedichte in Deutschland hat in der Vergangenheit permanent zugenommen. Anschließend erfolgt eine Beschreibung der Konzeption und Entwicklung der ärztlichen Bedarfsplanung im ambulanten Sektor. Auf Grund der Bedarfsplanung konnte die Arztzahlentwicklung gebremst werden. Die Betrachtung der Alterstrukturentwicklung verdeutlicht, dass das Durchschnittsalter der Vertrags- und Krankenhausärzte in den letzten zehn Jahren kontinuierlich zugenommen hat. Dies resultiert einerseits aus einem wachsenden Anteil von älteren Ärzten und andererseits aus einem Rückgang des Anteils der jungen Ärzte. Als Ergebnis der Analyse der Nachwuchsentwicklung ergibt sich, dass die Zahl der Studienplatzabbrecher bzw. -wechsler in den letzten Jahren permanent zugenommen hat. Zudem werden immer weniger Nachwuchsmediziner in der Patientenversorgung tätig, sondern nehmen Berufsalternativen wahr. Zugleich ist auch zu registrieren, dass die medizinische Profession weiblicher wird, da der Ärztinnenanteil in den letzten Jahren und Jahrzehnten permanent zugenommen hat. Bei den Medizinstudenten stellen Frauen bereits jetzt die Majorität. Die mangelnde Bereitschaft junger Mediziner kurativ tätig zu werden in Verbindung mit der ungünstigen Alterstruktur der berufstätigen Ärzte führen zu einem Mangel an Ärztinnen und Ärzten in Teilbereichen der Versorgung. In den Krankenhäusern, besonders ausgeprägt in den neuen Bundesländern, können viele vakante Arztstellen nicht mehr besetzt werden. Im ambulanten Sektor der neuen Länder sind Arztzahlrückgänge zu verzeichnen, besonders ausgeprägt bei den Hausärzten. Als Konsequenz ergibt sich, dass die Rahmenbedingungen der ärztlichen Tätigkeit insgesamt verbessert werden müssen, um den Beruf wieder attraktiver zu gestalten. This article deals with the numerical development of physicians as the main actors in the German health care system. Firstly the article describes the general and sector-specific development of the past. Over the years the density of physicians in Germany has continuously increased. Secondly, the article gives a description of the needs-related planning in the ambulatory sector which succeeded in slowing down the trend in the number of doctors. Regarding the trend in age-structure, this article shows clearly that during the last ten years the average age has increased continuously. On the one hand, this is the result of the increasing proportion of older physicians and, on the other hand, of the reduction in the proportion of younger physicians. The result of the analysis of the development in trainee doctors shows that the number of college dropouts and college those changing has risen continuously during the last few years. In addition to this fewer and fewer young physicians operate in the patients’ care, but take up alternative jobs. At the same time it can be seen that the medical profession is becoming more and more female, since the proportion of female physicians has risen during the last ten years. Among medical students there is already a majority of female students. The willing of young health professionals to work in the curative sector in conjunction with the disadvantageous age-structure of the employed physicians lead to a lack of male and female physicians in subareas of health care. In the hospitals, especially in eastern Germany, many vacancies cannot be filled. In the ambulatory sector of the eastern Germany there is a decline in the number of doctors and especially of general practitioners. The consequence is that the basic conditions for medical jobs have to be improved to make this profession more attract.