How health kiosks could fill a gap in the healthcare system
Karl Lauterbach, Germany’s Federal Minister of Health, wants to set up health kiosks in disadvantaged areas to bring medical care closer to the people who need it most. But his plan has met with resistance from politicians and health insurers. Professor Andrea Kießling, who specializes, among other things, in public health law at Goethe University Frankfurt, is examining the legal aspects to see how health kiosks could be put into practice
“In an ideal world,” admits Andrea Kießling, “there would be no need for health kiosks.” But as Kießling, who is Professor of Public Law, Social and Health Law and Migration Law at Goethe University Frankfurt, knows only too well: The German healthcare system is pretty far away from an ideal world. With its complicated structures tailored to maintaining the balance between powerful interest groups such as doctors, hospital associations, pharmaceutical companies and health insurers, the system places excessive demands on patients in terms of what experts like Kießling call “health literacy”: useful knowledge about opening times or the range of services offered by general practitioners. That general practitioners and even health insurance companies can arrange appointments with specialists, for example. Or that doctors on emergency call are often a better alternative on weekends than overburdened emergency rooms at hospitals. The complexity of the German healthcare system is particularly overwhelming for people with mental health problems, limited education or insufficient language skills. In Germany, they often end up at the doctor’s too late or directly in the emergency room.
To facilitate access to the healthcare system and guide patients to the right port of call, Karl Lauterbach, Federal Minister of Health, wants to set up health kiosks throughout Germany – especially in disadvantaged areas with a high population of immigrants or people who are frail, chronically ill or receiving government benefits, but with few GPs, pediatricians, psychotherapists and nurses to treat them.
Professor Andrea Kießling, an expert in social and health law at Goethe University Frankfurt, believes that the idea could have potential and recently published a study entitled “Health kiosks as a subject of health law between social space and statutory health insurance” [Gesundheitskioske als Gegenstand des Gesundheitsrechts zwischen Sozialraum und gesetzlicher Krankenversicherung] with research associate Amelie Folttmann. In addition, she also organized a conference of renowned health lawyers and practitioners in Berlin on “Access to the Healthcare System”. Kießling believes that if health kiosks are easily accessible at train stations or in pedestrian zones, open to everyone without an appointment and staffed by nurses who speak foreign languages, they could initially assess symptoms in an unbureaucratic way and, if necessary, also arrange doctor’s appointments. Conversely, doctors could refer patients to health kiosks for assistance with dietary changes or medication plans. People who might find it difficult to apply for prescribed medical appliances such as hearing aids could obtain help in the health kiosk with filling out application forms or calling their health insurer, or at least be referred to specialists at welfare associations or independent patient counselling. The Federal Ministry of Health hopes that health kiosks could prevent or at least curb diseases such as high blood pressure, obesity or type 2 diabetes, relieve doctors – and ultimately save costs. An initial study cited by Kießling describes the positive impact of the first health kiosk set up as part of a pilot project in 2017 in Billstedt, a Hamburg suburb, which resulted in a drop in avoidable hospital treatments there. However, like all preventive measures, health kiosks will also initially entail costs: around €400,000 per kiosk per year according to the Federal Ministry of Health and healthcare experts. Extrapolated to 1,000 kiosks throughout Germany, the annual cost would amount to €400 million. Although this is paltry in comparison to the almost €466 billion that the German healthcare system cost in 2021 according to the Federal Statistical Office, it is a lot of money in times of rising health insurance premiums and intense pressure on public budgets to save money.
Lauterbach: Health insurance companies and municipalities should share the costs
Karl Lauterbach, Federal Minister of Health, says that the statutory health insurers should be primarily responsible for raising the funds: He currently plans for them to bear almost three quarters of the costs. Cities and municipalities would also have to contribute around 20 percent to subsidize health kiosks in their catchment area. Many of them are, however, in the red, and especially municipalities whose residents would particularly benefit from health kiosks are more likely to be lacking the required funding, for example cities and municipalities with a lot of people receiving government benefits. “Due to financial dearth, municipalities might refrain from demanding that statutory health insurers set up health kiosks,” warns Andrea Kießling. Incidentally, no one can force municipalities to set up health kiosks – not even the Federal Minister of Health. Experts like Kießling call this a “ban on top-down decisions”.
Opposition from politicians and health insurance companies
Lauterbach certainly experienced the limitations of ministerial power. Increasing resistance to health kiosks is forming both in the Free Democratic Party (FDP), previously a coalition partner in the Federal Government, and in the German Association of Towns and Municipalities [DStGB – Deutscher Städte- und Gemeindebund], which represents local authorities’ interests. The latest draft bill “to strengthen healthcare in municipalities” no longer included health kiosks, although Lauterbach made it clear that he was sticking to his plans.
Critical politicians fear that health kiosks will lead to expensive parallel structures and statutory health insurers are concerned for the same reasons. Health insurers have already withdrawn from the first health kiosk in Hamburg-Billstedt. Barmer, DAK-Gesundheit and Techniker Krankenkasse have all stated that advisory services offered at kiosks are not the responsibility of statutory health insurers but rather a matter for public services. Put bluntly: The municipality should bear the costs alone. As in Hamburg, health insurers could obstruct the establishment of health kiosks throughout Germany. To avoid this, Kießling advises that the law should clearly stipulate when health insurance companies are obliged to co-finance health kiosks. For example, the Federal Government could force statutory health insurers to co-finance health kiosks with municipalities by law if the percentage of residents receiving government benefits or other people in need exceeds the threshold, such as in Hamburg-Billstedt.
Finance is the key issue
Opposition from politicians and health insurers shows that Lauterbach’s plans for health kiosks are at least at risk of cuts. This already occurred after Barmer and other insurers opted out of the health kiosk pilot project in Hamburg-Billstedt: Although AOK and Mobil Krankenkasse continued to finance the local health kiosk – the project agency “Gesundheit für Billstedt-Horn” was forced to announce “painful cuts in personnel and services and a reduction in services to only members of the two statutory health insurance companies” left funding the project. For Andrea Kießling, selective contracts between individual health insurance companies and municipalities are only emergency solutions that limit the benefits of health kiosks: “The kiosks are intended to provide easy access to the health system not only for members of the specific health insurance scheme but for anyone seeking medical assistance,” she says, adding: “If the demand for advice and support in health matters identified by the Ministry of Health truly exists, we must ask how this need can be met now that health kiosks have been removed from the draft bill.”
About / Andrea Kießling, born in 1981, has been Professor of Public Law, Social and Health Law and Migration Law and Director of the Institute for European Health Care Policy (INEGES) at Goethe University Frankfurt’s Faculty of Law since 2022. In 2021, she completed her postdoctoral degree (Habilitation) on “The Law of Public Health. Disease Prevention and Health Promotion as Tasks of the State” [Das Recht der öffentlichen Gesundheit. Krankheitsprävention und Gesundheitsförderung als Aufgaben des Staates] at Ruhr University Bochum. During the coronavirus pandemic, she was regularly consulted as an expert in legislative procedures on amendments to the Infection Protection Act. At Goethe University Frankfurt, Andrea Kießling is also the scientific director of the Goethe University Law Clinic.
kiessling@jur.uni-frankfurt.de
The author / Jonas Krumbein, born in 1985, studied history and political science in Freiburg and Durham (England) and works part-time as a freelance journalist.
j.m.krumbein@icloud.com
