“The question would be: May be made with the health of other people and especially on the backs of nurses and I say “No”. You can start with this question, to then answer all subsequent ones”
One of hundreds of outpatient nursing service cars in Kassel
In the year 2018 Health Minister Jens Spahn promised, that wage dumping has ended in outpatient care. However, wages in the care sector are still low and wage payments according to the tariff are rare. The nursing service PHB e.V. in Hofgeismar, a non-profit association, pays from the beginning of July 2020 his 110 Nursing staff in non-clinical intensive care wages. For that he has 1 Disputed with health insurance companies for ½ years. This means an average of € 700 more gross for full-time employees.
We interviewed Max, for the PHB e.V. negotiated with the health insurance companies. The first step was the lengthy negotiation process. In conversation, the crux in the area of outpatient care became clear: Compared to other industries, nurses cannot directly demand wages for wages from their employers - the outpatient nursing services – push through, but are dependent on it, that they negotiate wages with the health insurance companies. However, many nursing services often lack knowledge and resources due to the design of the health sector. That explains, among other things, why just the political and legal statement, that health insurance companies have to recognize collective wages as economical, does not lead to that, that the nursing staff also receive collective wages in the end.
The interview was conducted Franka Füller
press department: In the area of outpatients Intensive care, a part of outpatient care, a care contract is negotiated between the nursing service and the health insurance company. Among other things, this determines the wages of the nursing staff. Can you explain briefly, how this negotiation process typically works?
Max: Basically, it is: The health insurance company sees a basic wage increase of approx. 2 to 3 % vor. The service provider, so the nursing service, can accept this base wage increase. And if you don't accept it, to really raise wages, one enters into individual negotiations with the health insurance companies. The health insurance then checks the nursing service under two criteria. The first criterion is that of plausibility. This means, that the nursing service must disclose all of its figures. The health insurance company then checks the figures, what material costs, Overhead- costs, Personnel costs are plausible and what are not. The second step is that of economic efficiency. This means, the health insurance company is entitled to do this, to assess, whether that, was man z.B. in terms of wages or what you want to pay in terms of property- or overhead costs, is economical or not. This second step of profitability is always based on external comparison. That means, that the health insurance company compares you with other care services and of course the problem is always there, that you are compared with the cheapest ones. Those are the ones that are cheap, the annually the 2 or 3 % Accept a basic wage increase. These are the two testing steps, that you have to go through, if you e.g. Wants to pay the tariff or generally wants to increase the hourly wage by two or three euros.
You have now made it through the negotiation with the health insurance companies, to enforce a collective wage. Why, Do you believe, Wage dumping is not uncommon in the area of outpatient care, but the standard?
First you have to see, that there are incredibly different providers in the care industry. In addition to non-profit organizations like ours, there are of course also larger organizations such as Diakonie or Caritas. There are also investor-driven holding companies, who have their individual locations everywhere. With this patchwork it is incredibly difficult, to negotiate a comprehensive tariff. And on the other hand, there are hardly any union memberships for outpatient nurses. Nurses have been used to it for a long time, to work at lower wages and there is often a lack of energy, to demand fairer pay. In this patchwork quilt, everyone is on their own. Many are self-organized as small businesses and are not big enough, that there is a works council. And if you then look at the investor-driven care services, then it becomes clear, that they have an interest in it, Paying just above minimum wage, in order to keep the profit margin as high as possible. But also the little ones, Non-investor-driven care services often do not pay standard wages. It is important to understand this, to look at, , how most outpatient care services are structured, because they are often small and only have 15 or 20 Employees. The responsible nursing service manager usually comes from a nursing background and decided to do so at some point, to open a small nursing service. The skills in business administration or economics are often not available, calculate the costs down to the last cent and present the complete figures to the health insurance company in a plausible manner.
Then the demand for cost-effectiveness has a fatal impact on wages, if the point of comparison is always the nursing service, who doesn't pay standard wages.
Exactly! This factor of external comparison is an absolute farce, if you want to pay standard wages and profitability always means comparing with the cheaper provider! But these are often precisely the nursing services, who do not have the competence, to negotiate this or not necessarily know about this possibility. These are, among other things, problems, which lead to wage dumping.
How you describe the negotiation process, that sounds like, as if the review process were entirely the responsibility of the health insurance companies. What options do you have as a nursing service?, to negotiate a collective wage?
About the regulations in the Social Security Code (SGB) there are different jurisdictions, because a few nursing services have gone to court. Case law says that the economic viability test should be carried out, that the economic efficiency is given when paying collectively agreed wages. There is, for example. a judgment of the Federal Court of Justice (BHG), that we have always relied on. We just found out about it, when we heard a lawyer's lecture, who pointed this out, that this case law exists and that it represents a legal basis, to earn collective wages.
How did you proceed then??
We picked out all these case laws and referred to them in the negotiations. The health insurance companies' first reaction to our demand for collective wages was initially “No, We won't give that to you, but we give to you 2,8 % more”. Then we argued, that it is our right, that the economic viability is not in doubt up to the level of the collective wage. And if you look at the tariff, for us e.g. the collective agreement for the public service (TVÖD), it's about a difference 30 to 35 % which only concerns the wages. And there are other components of the tariff as well, such as. better pension provision, etc.
What is happening, if an agreement cannot be reached in such a negotiation?
If the nursing service and health insurance company can't manage it, to reach agreement in individual negotiations, this negotiation is declared to have failed and the proceedings are submitted to arbitration. Then we go into an eight-hour negotiation marathon together. If there is no agreement afterwards, the arbitrator decides, how is paid.
Another of hundreds of outpatient care service cars in Kassel
What would you say to other nursing services?, who also fight for a collective wage, advise or. give on hand, what you learned from your negotiations?
For one thing, it’s important, not to be afraid of it, to enter into these individual negotiations. You then have to be pretty familiar with the numbers and work into them. But actually, I think that's the only way. In addition, it is also related to associations, provide materials, to process all important information about these negotiations. In the end, it's also about simple things, z.B. to communicate with each other briefly. That can also mean, to approach nursing services, who have already negotiated tariffs, to ask, whether you can get their Excel templates, which were expected. If it's the know-how, What is missing, you should try, to get it somehow.
So it would be important, to work towards greater networking between nursing services?
Exactly! The process is just very intimidating in many places. In addition to legal knowledge, that you have to have, There is also a lot of pressure from health insurance companies and a negotiation climate, that you have to endure. However, the negotiating climate is not the same at all health insurance companies and in some cases there has been a change. Nevertheless, it is important not to do this alone, but to look, what connecting points there are in the respective structures, where you can look for colleagues. If you do it alone, it's very grueling. And it shows, that many give up within this process. We have the process 1 Took ½ years. And on top of that, we had to negotiate individually with all of our patients’ health insurance companies. In total we conducted nine individual negotiations, with the Barmer, the DAK, the technician health insurance company, the AOK Hessen, the AOK Nordwest etc. usf. And some of these funds then agree to the collective wage, some say “no”. We were almost at a cash register, to involve the supervisory authority, because she hasn't even told us yet, which arbitrator you agree to. You can see a strategy there, which is designed to demobilize nursing services in the negotiation process.
In our preliminary conversation you spoke about the neoliberalization of care. What exactly do you mean by that??
What was introduced in the clinics with the flat rates per case, is found similarly in outpatient care. In both test steps, plausibility and cost-effectiveness, Everything has to be calculated down to the last cent. Then you argue about it, how many people actually have to sit in the office, to do personnel accounting. And that is often said “Oh no, two places? This is too much”. Normally you always have a bit of play, this is called the risk premium, so the return, that lies between 4 and 6%. However, it becomes apparent in outpatient care, that if you centralize the structures for e.g. 50 Nursing services have a central administration, Then you can reduce the administration costs and then have a return of up to 15%. And that's what made it attractive for investors, to get in there.
When I look at the debate about low wages in outpatient care, A question seems to be recurring to me: Does the responsibility for poor pay lie with the individual providers or with the legal framework and the financing system? On the one hand you can argue, that there is room for maneuver for management to negotiate with the health insurance companies and that they are employers, the one Responsibilityung for the wage level. And on the other side you can represent, that the problematic profit orientation and the efficiency requirement of the industry are laid down in laws and the financing system and have a significant impact on the structure of the industry. Do you have this question and if so?, How do you answer it??
I see the problem with that too, that there is responsibility, to fight for it, with the service providers or. lies with the individual management of the respective nursing services. So that's definitely the problem. But it is, I think, a basic problem, that outpatient care must be about returns or. can, because it is about an absolutely relevant basic service for society. Would you want to change that?, However, completely different structures would have to be created. Privatization is here, in my opinion, the basic problem. The question would be: May be made with the health of other people and especially on the backs of nurses and I say “No”. You can start with this question, to then answer all subsequent ones. But that would mean a complete reform of the SGB and of course the structures, that were created. Ultimately there needs to be a debate about this.
Thank you for the conversation!