Introduction
In an intensive care unit, an unoccupied bed may be perceived as available capacity. Viewed from the perspective of hospital financing, that same bed nevertheless represents an entire infrastructure that must continue to function before a patient even needs it: qualified staff available twenty-four hours a day, medical equipment, medications, diagnostics, hygiene, logistics. Availability comes at a cost, even when the bed remains empty.
This tension between what the patient sees and what the organisation must maintain, between what the budget measures and what care cannot fully translate into numbers, lies at the heart of the financing and organisational mechanisms of the German hospital system. A hospital does not simply fund medical procedures. It must permanently maintain teams, laboratories, radiology, IT, energy, and emergency capacities. A portion of the hospital's cost resides precisely in what must be available before it is used.
Yet, this economic necessity cannot justify just any kind of organisation. Efficiency is not the enemy of medicine: it is legitimate to eliminate unnecessary processes and use limited resources intelligently. But a hospital cannot be thought of as an industrial organisation where one hundred percent of capacities should be utilised at all times. In intensive care, in particular, an unused reserve today may become indispensable a few minutes later. The most effective model is not one of maximum utilisation, but an organisation that reduces waste while retaining enough stability when care needs suddenly exceed what was planned.
This reflection takes on particular resonance in the context of the German hospital financing reform, which is intended progressively to fund a growing share of hospital budgets independently of the number of cases treated. For Tamara Stenger, economic incentives will not disappear with the new model: they will change form. The real challenge will be to determine whether this reform brings financing, quality, appropriate specialisation, and the actual availability of care closer together.
But more funding is not necessarily enough. Her experience as a nurse shifts the debate: the question is not only "how much money is spent on care?" but also "how is healthcare professionals' time actually used?" Documentation, organisation, searching for equipment, poorly functioning interfaces, scheduling, management: an increase in resources only truly improves the system if it translates into better working conditions and more time with patients.
Finally, there is what the numbers do not measure. A hospital can track costs, activity, absenteeism, overtime, staff turnover, and medical outcomes. But these indicators often appear only when the consequences are already visible. The more fundamental question remains: can a healthcare system integrate the human reality of those who make it work without reducing that very reality to an economic variable?
Tamara Stenger's perspective sits at the intersection of these tensions. After working for about fifteen years in intensive care and anaesthesia, she moved into the field of hospital budget management. This background allows her to view the same reality from two perspectives that are usually separate: the patient's bed and the financing of the structure that allows that bed to exist. She makes clear that her answers reflect her personal professional assessment and experience, and do not constitute an official position of her employer.
Under what conditions can a financial reform be considered successful if its effects are visible not only in a hospital's accounts, but also in the day-to-day work of healthcare professionals, the time returned to patients, and the hospital's capacity to maintain care when it becomes necessary? Eight questions to examine these two realities within the same system.
Editorial note
Proofread and corrected version — linguistic and syntactic corrections, with no change to the substance.
The interview
Two Perspectives on the Hospital
JLPdecryptage
You worked for fifteen years in intensive care and anaesthesia before moving into budget management. What do you understand differently today, with your current knowledge of hospital financing, regarding certain situations you experienced directly in patient care at the time? And conversely: what realities of care are difficult to translate into a budget?
Tamara Stenger
Today, I understand much better why certain things in a hospital cannot be decided solely based on what seems medically or organisationally sensible at first glance. Behind many structural and organisational decisions, there is now for me an additional question: how is this service funded? Are the costs actually reimbursed? What structures must be maintained, even if they cannot be directly attributed to a single case?
As an intensive care nurse, for example, I primarily saw an available ICU bed as an available treatment capacity. Today, I also see what is necessary to make that bed operational at any given time. Qualified staff around the clock, medical equipment, medications, diagnostics, hygiene, logistics, and many other structures. Maintaining these capacities costs money, even when no patient is in that bed at that moment.
Conversely, there are things that are very difficult to translate into numbers. How do you account for the fact that a nurse stays an extra ten minutes with an anxious patient?
Or that an unstable patient requires the attention of an entire team within a few minutes? Care is not entirely predictable. Especially in an intensive care unit, a situation can change in a matter of seconds.
This is probably my most important conclusion drawn from these two worlds. A hospital needs financial and economic management, but the reality of care can never be fully translated into Excel spreadsheets, case volumes, or budgets.
What Treatment Really Costs
JLPdecryptage
For patients, a hospital stay is often experienced primarily through the doctors, nursing staff, and medical services patients encounter directly. However, behind every treatment lies a vast staffing, technical, and logistical infrastructure. What particularly important cost factors are underestimated by the general public—and sometimes even by healthcare professionals—when talking about the "costs" of a treatment?
Tamara Stenger
When we talk about the costs of a treatment, we often only see what happens directly with the patient, such as medical treatment, nursing care, diagnostics, medications, or a surgical procedure. In reality, there is a much broader infrastructure behind it.
A hospital must be functional 24 hours a day. For this, it needs not only doctors and nurses, but also, for example, a laboratory, a radiology department, a pharmacy, a sterilization service, operating room infrastructure, medical equipment, IT services, hygiene, cleaning, logistics, a kitchen, energy supply, and technical services. Many of these structures must be permanently available, regardless of whether they are fully utilised at that exact moment.
Added to this is a point often little known outside the healthcare sector: the dual system of hospital financing. Current operating costs, that is to say, for example, personnel, medications, medical supplies, energy, or other costs of the hospital's daily operations, are financed essentially by health insurance funds or payers.
Investments, on the other hand, are in principle the responsibility of the Länder. This includes, for example, major construction projects or long-term investments in hospital infrastructure. In theory, this separation is clear. In practice, the two areas are closely intertwined, especially when necessary investments are not fully funded or funded in time, and hospitals have to absorb additional burdens from their current operations.
What is also often underestimated are the costs of medical innovations. New medications, implants, or innovative therapies can generate considerable costs. It is precisely here that we see very clearly, from my current perspective, that medical progress is always also a question of financing and reimbursement.
Therefore, the true cost of hospital treatment does not consist solely of the individual medical service. It also encompasses the staffing, technical, and organisational structures necessary for that treatment to take place safely at any time.
This is precisely what is often underestimated in the public debate about the "costs" of a hospital stay.