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Hospitalization: A Contentious Issue for Patients and Health Funds in Baden, 1893–1914
Published online by Cambridge University Press: 26 July 2012
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Hospitals in Germany had traditionally provided care on a voluntary basis. Before the end of the nineteenth century, hospitalization was compulsory only during epidemics or in the case of infectious diseases such as syphilis or leprosy. Voluntary hospitalization normally occurred only when hospital beds were available, when payment was guaranteed, or during emergencies. Towards the end of the nineteenth century, however, there was a definite increase in hospitalization levels, primarily due to two important developments: the introduction of health insurance in 1883, and the growing number and size of hospitals. Health insurance covered its members' hospital expenses, and the hospitals provided facilities for more and more patients.
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1 For example, in 1877 there were only 72,219 hospital beds throughout the German Reich, but this number almost quadrupled in less than forty years, reaching 226,831 by 1911. This means that for every 10,000 persons, there were roughly 16.5 beds in 1877 and about 41.5 beds in 1911. See Reinhard Spree, Soziale Ungleichheit vor Krankheit und Tod. Zur Sozialgeschichte des Gesundheitsbereichs im Deutschen Kaiserreich, Göttingen, Vandenhoek & Ruprecht, 1981, p. 101.
2 For a comparative view of the history of health insurance, see E P Hennock, British social reform and German precedents: the case of social insurance 1880–1914, Oxford, Clarendon, 1987; Wolfgang J Mommsen (ed.), The emergence of the welfare state in Britain and Germany 1850–1950, London, Croom Helm, 1981; and Gerhard A Ritter, Der Sozialstaat. Entstehung und Entwicklung im internationalen Vergleich, 2nd ed., Munich, Oldenbourg, 1991.
3 In the year 1885, around 10 per cent of the German population were members of a health fund; by 1913, the number had risen to around 25 per cent. See Florian Tennstedt, ‘Sozialgeschichte der Sozialversicherung’, in Maria Blohmke, et al. (eds), Handbuch der Sozialmedizin. Band 3: Sozialmedizin in der Praxis, Stuttgart, Enke, 1976, pp. 385–492, on p. 386.
4 On the subject of the self-government of the sickness funds, see Florian Tennstedt, Soziale Selbstverwaltung. Geschichte der Selbstverwaltung in der Krankenversicherung von der Mitte des 19. Jahrhunderts bis zur Gründung der Bundesrepublik Deutschland, Bonn, Verlag der Ortskrankenkassen, [1977].
5 See, for example, Tennstedt, op. cit. note 3 above, pp. 389–90, Sylvelyn Hähner-Rombach, Die Betriebskrankenkassen in Baden und Württemberg von der Industrialisierung bis in die Zeit des Nationalsozialismus. Eine Chronik, Tübingen, Silberburg, 2001, p. 68.
6 See, for example, Ingo Tamm, Ärzte und gesetzliche Krankenversicherung in Deutschland und England 1880–1914, Berlin, Verlag für Wissenschafts- und Regionalgeschichte, 1998, p. 123.
7 See Tennstedt, op. cit., note 3 above, p. 390.
8 For an overview of research in the social history of medicine, see Martin Dinges, ‘Social history of medicine in Germany and France in the late-twentieth century’, in Frank Huisman and John Harley Warner (eds), Locating medical history: the stories and their meanings, Baltimore, Johns Hopkins University Press, 2004, pp. 209–36.
9 See Jens Lachmund and Gunnar Stollberg, Patientenwelten. Krankheit und Medizin vom späten 18. bis zum frühen 20. Jahrhundert im Spiegel von Autobiographien, Opladen, Leske & Budrich, 1995.
10 Barbara Elkeles, ‘Der Patient und das Krankenhaus’, in Alfons Labisch and Reinhard Spree (eds), “Einem jeden Kranken in einem Hospitale sein eigenes Bett”. Zur Sozialgeschichte des Allgemeinen Krankenhauses in Deutschland im 19. Jahrhundert, Frankfurt and New York, Campus, 1996, pp. 357–73.
11 Not only is there a scarcity of source material relating to health insurance companies' disputes with members, but research in this field is rather rare. The history of patients, at least in respect of health insurance companies in German-speaking countries, is only beginning to emerge. Recently Alfons Labisch and Reinhard Spree stated that in Germany more research is required on the situation of patients in hospital. See the introduction of Alfons Labisch and Reinhard Spree (eds), Krankenhaus-Report 19. Jahrhundert. Krankenhausträger, Krankenhausfinanzierung, Krankenhauspatienten, Frankfurt and New York, Campus, 2001, pp. 13–37, on p. 22.
12 In 1897, on average 383,581 people were members of a compulsory health insurance in the Duchy of Baden, with altogether 130,060 cases of illness. (Unfortunately no information about the numbers hospitalized could be found.) See Großherzogliches Statistisches Landesamt (ed.), Statistische Mittheilungen über das Großherzogthum Baden, XV. vol. 25, Karlsruhe, 1898, pp. 220, 221. By comparison with these figures, 991 lawsuits between 1893 and 1914 is low. But, as already noted, sources are scanty and these lawsuits not only add to the records but also provide another source for research.
13 In 1903 the period was extended to twenty-six weeks.
14 The health funds were not obliged by law to pay for hospital care; they could use their discretion. See, for example, Alfons Labisch, ‘Stadt und Krankenhaus. Das Allgemeine Krankenhaus in der kommunalen Sozial- und Gesundheitspolitik des 19. Jahrhunderts’, in Labisch and Spree (eds), op. cit., note 10 above, pp. 253–96, on p. 267.
15 With the introduction of health insurance, the fear—or rather suspicion—grew that people would stay away from work on the pretext of being ill. Consequently, the health funds often set up control mechanisms. There is little research on malingering in relation to health insurance. There is a thesis by Anna-Maria Schuster on ‘Simulation von Krankheiten in der zweiten Hälfte des 19. Jahrhunderts unter besonderer Berücksichtigung der Sozial-versicherungsgesetzgebung der späten 1880er Jahre’, University of Stuttgart, 2001. For other examples, see Ingrid von Stumm, Gesundheit, Arbeit und Geschlecht im Kaiserreich am Beispiel der Krankenstatistik der Leipziger Ortskrankenkasse 1887–1905, Frankfurt/Main, Lang, 1995, pp. 41–3.
16 Generallandesarchiv (hereafter GLA) Karlsruhe, Bestand 239, Nr. 7146.
17 Between 1896 and 1913, the sickness funds in Baden paid out between 1.82 and 5.81 marks per member per year for hospital care and between 5.00 and 15.68 marks per member per year for sick pay. See Hähner-Rombach, op. cit., note 5 above, pp. 108–9. As the sickness funds did not have to pay for medical care in hospital (at least until 1913), they were more interested in inpatient treatment than in ambulant treatment. See Bernd Nierlich, Krankenhausärzte und Krankenhauspatienten. Ihre psychosoziale und sozialrechtliche Darstellung im Deutschen Ärzteblatt und in der Münchener Medizinischen Wochenschrift im Zeitraum von 1885–1945. Ein inhaltsanalytischer Vergleich, Herzogenrath, Murken-Altrogge, 1991, p. 144. For the financing of the hospitals in this period, see Gunnar Stollberg and Ingo Tamm, Die Binnendifferenzierung in deutschen Krankenhäusern bis zum Ersten Weltkrieg, Stuttgart, Franz Steiner, 2001; Labisch and Spree (eds), op. cit., note 11 above.
18 Supervisors were used elsewhere. The big local insurance company in Leipzig with 103,492 members in 1896, employed 184 voluntary supervisors (called visitors), who made 79,332 visits in that year. Another thirteen professional supervisors made 146,899 visits. See Alfons Labisch, Homo Hygienicus. Gesundheit und Medizin in der Neuzeit, Frankfurt and New York, Campus, 1992, p. 182.
19 This led sometimes to the sickness fund losing the lawsuit because it changed the reason for hospitalization.
20 GLA Karlsruhe, Bestand 239, Nr. 6694.
21 These numbers declined over time. In 1886, 49 persons out of 100 were members of a company health insurance fund, in 1914 only 26.5. See Hähner-Rombach, op. cit., note 5 above, pp. 98–9.
22 For TB patients who were sent to a sanatorium for three months the financial problems were even worse, and resulted sometimes in the patients leaving the sanatorium without authorization, see Sylvelyn Hähner-Rombach, Sozialgeschichte der Tuberkulose. Vom Kaiserreich bis zum Ende des Zweiten Weltkriegs unter besonderer Berücksichtigung Württembergs, Stuttgart, Franz Steiner, 2000, pp. 327–8.
23 Elkeles writes that, despite the progress made in hospital therapy and hygiene in the nineteenth century, at the beginning of the twentieth century people still tried to avoid hospitalization, mainly because of the low quality of nursing care, the bad state of the buildings and poor hygiene. Bureaucracy and rigorous house rules further aggravated the situation. See Barbara Elkeles, ‘Das Krankenhaus um die Wende vom 19. zum 20. Jahrhundert aus der Sicht seiner Patienten’, Historia Hospitalum', 1986/88, no. 17, pp. 89–105.
24 See, for example, the boycott of the Charité in Berlin in 1893, in Reinhard Freiberg, ‘Der Charité-Boykott im Jahre 1893. Eine medizinhistorische Studie über Auswirkungen der Arbeitersozialreformen der 80er und 90er Jahre des 19. Jahrhunderts’, PhD thesis, Humboldt-Universität Berlin [1997], idem, ‘Der Charité-Boykott im Jahre 1893’, in Peter Schneck (ed.), Medizin in Berlin an der Wende vom 19. zum 20. Jahrhundert, Husum, Matthiesen, 1999, pp. 141–50. In this case, the sickness funds in Berlin worked together with the Social Democrats in favour of their members against the hospital. The conditions in hospitals did not improve generally, however. The following was written as late as 1913: “Beispielsweise ist es schon vorgekommen, daß die Einrichtungen des Krankenhauses so unzulänglich waren, oder daß der Aufenthalt im Krankenhause als so schädlich für den Kranken erachtet werden mußte, daß die Gerichte in dem Verlassen des Krankenhauses eine unbefugte Handlung nicht erblicken konnten.” Deutsche Krankenkassen-Zeitung, 1913, 13: 17.
25 See Elkeles, op. cit., note 10 above, p. 362.
26 See Deutsche Krankenkassen-Zeitung, 1909, 9: 216.
27 GLA Karlsruhe, Bestand 239, Nr. 7202.
28 GLA Karlsruhe, Bestand 239, Nr. 7202.
29 GLA Karlsruhe, Bestand 239, Nr. 6671.
30 GLA Karlsruhe, Bestand 239, Nr. 7366.
31 GLA Karlsruhe, Bestand 239, Nr. 6994.
32 GLA Karlsruhe, Bestand 239. Nr. 7351.
33 GLA Karlsruhe, Bestand 239, Nr. 7269.
34 GLA Karlsruhe, Bestand 239, Nr. 6577.
35 GLA Karlsruhe, Bestand 239, Nr. 6671.
36 GLA Karlsruhe, Bestand 239, Nr. 6453.
37 GLA Karlsruhe, Bestand 239, Nr. 6508.
38 Given that there were physicians who needed some time to accept bacteriological findings regarding TB, it is not surprising that acceptance among patients took longer. For the debates among British physicians, see Michael Worboys, Spreading germs: disease theories and medical practice in Britain, 1865–1900, Cambridge University Press, 2000, pp. 193–233.
39 For the relationship in general between physicians and patients from the end of the eighteenth century to the early twentieth century, see, for example, Claudia Huerkamp, ‘Ärzte und Patienten. Zum strukturellen Wandel der Arzt-Patient-Beziehung vom ausgehenden 18. bis zum frühen 20. Jahrhundert’, in Alfons Labisch and Reinhard Spree (eds), Medizinische Deutungsmacht im sozialen Wandel des 19. und frühen 20. Jahrhunderts, Bonn, Psychiatrie-Verlag, 1989, pp. 57–73. For the relationship after the introduction of the health insurance, see, for example, Claudia Huerkamp, Der Aufstieg der Ärzte im 19. Jahrhundert. Vom gelehrten Stand zum professionellen Experten: Das Beispiel Preußens, Göttingen, Vandenhoek & Ruprecht, 1985, pp. 216–24.
40 GLA Karlsruhe, Bestand 239, Nr. 6452.
41 GLA Karlsruhe, Bestand 239, Nr. 6689.
42 GLA Karlsruhe, Bestand 239, Nr. 6678.
43 GLA Karlsruhe, Bestand 239, Nr. 6673.
44 GLA Karlsruhe, Bestand 239, Nr. 6745.
45 GLA Karlsruhe, Bestand 239, Nr. 6895.
46 See, for example, Tamm, op. cit., note 6 above, ch. 3; Hedwig Herold-Schmidt, ‘Ärztliche Interessenvertretung im Kaiserreich 1871–1914’, in Robert Jütte (ed.), Geschichte der deutschen Ärzteschaft. Organisierte Berufs- und Gesundheitspolitik im 19 und 20. Jahrhundert, Köln, Deutscher Ärzte-Verlag, 1997, pp. 43–95, on pp. 82–95.
47 An extreme example of the observation of ill members is given in Marlene Ellerkamp, Industriearbeit, Krankheit und Geschlecht. Zu den sozialen Kosten der Industrialiserung: Bremer Textilarbeiterinnen 1870–1914, Göttingen, Vandenhoek & Ruprecht, 1991, pp. 219–220.
48 GLA Karlsruhe, Bestand 239, Nr. 6895.
49 GLA Karlsruhe, Bestand 239, Nr. 6477.
50 GLA Karlsruhe, Bestand 239, Nr. 6658.
51 GLA Karlsruhe, Bestand 239, Nr. 6871.
52 GLA Karlsruhe, Bestand 239, Nr. 6934.
53 GLA Karlsruhe, Bestand 239, Nr. 7202.
54 They started with 49 per cent in 1886 and had 26.5 per cent in 1914. See Hähner-Rombach, op. cit., note 5 above, pp. 98–9.
55Arbeitersekretäre could be representatives of the trade unions or of the Protestant church. Their task was to support workmen in different fields, offering, among other things, legal assistance.
56 The problem of retrospective diagnosis will not be discussed here.
57 “Bekanntlich entsteht sehr oft zwischen den Angehörigen einer Krankenkasse und der Krankenkasse selbst Streit darüber, ob die Nichtbefolgung der Einweisung ins Krankenhaus seitens des Kassenmitglieds berechtigt war oder nicht.” Deutsche Krankenkassen-Zeitung, 1913, 13: 17. “Da die Kassen im Falle der Weigerung der Patienten [der Krankenhauseinweisung Folge zu leisten-S.H.] diesen fast immer die Krankenunterstützung entziehen, haben die Gerichte in zahlreichen Fällen zu entscheiden”. Deutsche Krankenkassen-Zeitung, 1909, 9: 216.
58 Of the relevant cases heard before the Verwaltungsgericht Karlsruhe between 1886 and 1914, only 31.6 per cent were won by members, a settlement was reached in 8.2 per cent; 5.1 per cent abandoned the lawsuit and 2 per cent of the cases were not heard because the plaintiffs failed to meet the deadline.
59 See ‘[D]er Angehörige einer Krankenkasse hat selbst in einem dringenden Falle keinen Anspruch auf Krankenhauspflege’, in Deutsche Krankenkassen-Zeitung, 1912, 12: 278.
60 In two very similar cases, the court of appeal supported the patients' argument that “when the physician at the hospital agreed to the patient's discharge, this cannot be interpreted as being against the will of the sickness fund”. Another married patient who was suspected of being a malingerer refused hospitalization after having asked his physician whether he as a married man was obliged to go. The doctor said it was doubtful whether he could be forced to follow the instructions of the sickness fund. The patient then refused hospitalization; the court agreed with him: “When his behaviour was influenced by the information given by the physician, this circumstance must excuse the patient”. Deutsche Krankenkassen-Zeitung, 1911, 11: 12, 279.
61Deutsche Krankenkassen-Zeitung, 1911, 11: 96.
62 In one case, a married member suffering from a lung disease was supposed to go to hospital without knowing the reason for his hospitalization, and therefore refused. The court sided with the patient: the sickness fund was obliged to tell him why he should go. Deutsche Krankenkassen-Zeitung, 1910, 10: 176.
63 See note 24 above for the boycott of the Berlin Charité.
64 GLA Karlsruhe, Bestand 239, Nr. 7202.
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