German Health Care Reforms_Knieps

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FIRST US-GERMAN SUMMIT ONPRIMARY CAREApril 8-10, 2010

FRANZ KNIEPS

HEALTH CARE REFORMSIN GERMANY

Strengthening Primary Care


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The German Health Care System

Largest branche in German economy, but not

respected as an industry 3.5 mill. employees and self-employed

Turnover of 260 bill. (some 170 bill. financed

by statutory health insurance) 11 % of GDP

Public-private mix of insurers and providers


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Full coverage of the population

88% covered by some 160 statutory healthinsurance funds (semi-Public)

10% covered by some 45 private health

insurance companies (half of them for profite) 1% covered by military forces and police

1% covered by welfare authorities

No one can loose coverage since the beginningof 2007


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Statutory health insurance (s.h.i.)

Bismarck type social health insurance (founded in1883, roots go back to the middle age)

Self-governance by elected representatives of

employers and employees under supervision offederal and state insurance agencies

Financed by income related contributions

(principle of solidarity)


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Statutory health insurance (2)

Comprehensive benefit package regulated by lawincluding primary care, specialists care, hospital care,

necessary drugs and medical devices, dental careand dentures, prevention, rehabilitation, long termcare (from a separate budget)

No financial or time limitations

Comparable low co-payments (some 15%) up to a

limit of 2% of the annual income (1% for people withchronic diseases)


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Statutory health insurance (3)

Freedom of choice for all insured Access to (nearly) every fund

Competition between the funds (focus on quality,

efficiency, provider selection)Complex risk equalization scheme between all

funds under the umbrella of a (virtual) national

fund (operated by 21 experts in the FederalInsurance Agency BVA)


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The German Health Care SystemPrivate health insurance

Access only for civil servants, self-employedpeople, employees with annual salaries above38.000 (Problem: Opting out of solidarity)

Risk related premiums Age

Gender

Health status

Limited acces or higher premiums for handicapedor sick people


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Private health insurance (2)

Benefit package relies on agreement betweeninsurers and insured

Higher co-payments and deductables on

individual choiceCompetition focussed on risk selection


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Relationsships to the providers

S.h.i. enrollees receive benefits in kind fromregistered providers (physicians, dentists, medical

centers, hospitals, pharmacists)

No direct financial relations between patients and providers

Enrollees can opt out and choose reimbursement on their ownrisk

Privately insured have to pay cash and are

reimbursed by their insurers


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The German Health Care SystemThe health care providers

Mostly private providers (Only some 40% of thehospitals are owned by communities or counties,university hospitals are mainly owned by thestates)

Ambulatory care and hospital care are strictlyseparated

Focus on acute care

Neglection of chronic care, multimorbidity,prevention, rehabilitation, long term care


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The German Health Care SystemThe physicians (2008-12-31)

421.700 physicians 319.700 working in the health care system

138.300 working in ambulatory care 12.600 working for salaries

5.900 working for privately insured only

120.000 self employed registered physicians (paneldoctors) 58.500 family doctors

61.300 specialists

153.800 working in hospitals 20.000 chef physicians


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The German Health Care SystemTrends

Spezialization (percentage of family doctors isdecreasing steadily)

Feminization (60% of newly registered physiciansare female)

Globalization (Growing numer of incoming andoutgoing health professionals)

Growing demand on salaried jobs

Attractive jobs in non-medical areas (administration,pharmaceutical industry,)


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The German Health Care SystemPolitical reactions

Health care reforms Structures

Incentives

Quality

Federal and state programs

Investments

Education and training

Image

Evidence based medicine and outcome measurement


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The German Health Care SystemThe legal base

First nationwide legal act in 1883 followingEmperors Message on Social Security in 1881

Long-standing social insurance act(Reichsversicherungsordnung) in 1911 (up to 1989)

Fundamental modernization and integration into theSocial Code in 1988

Main regulation in Book 5 of the Social Code (SGB V)


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The German Health Care SystemHealth care reforms

The Health Care Modernization Act (1992) Freedom of choice and access to (nearly) every fund

for every insured to increase competition betweenfunds

Universal risk equalization scheme between allstatutory funds (focussed on income, age, gender) toprevent risk selection

Freedom of choice between all primary carephysicians, but legal obligation for all insured tochoose a family doctor


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Health care reforms

The Health Care Reform Act (1988) First fundamental reform after second world war

Introducing reference price system for drugs and

medical devices

Unification Treaties and Acts (1990)


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Health care reforms

The Health Care Modernization Act (2)Defining basic principles of primary care Family and home based diagnoses and therapies

Continuity of care

Coordination of all types of care

Comprehensive documentation

Integration of prevention and rehabilitation

Integration of other health professions Defining who is a family doctor


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Health care reforms

The Long Term Care Insurance Act (1994) Implementing long term care insurance following

the principles of health insurance

Operated by the health insurance funds andcompanies with separated budgets and total fiscalequalization between the statutory funds

Only basic insurance to reduce dependancy on

welfare subsidies


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The German Health Care system

Health care reforms

The Health Care Reform Act 2000 Implementing new models of Care

Integrated care

German styled disease management programs for widespreaddiseases (diabetis, coronar heart diseases, asthma, breastcancer)

Implementing new payment systems for ambulatory

care and hospital services Separated budgets for family doctors

German styled DRG-System for nearly all hospital services


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Health care reforms

The Health Care Reform Act 2000

Improving quality assurance

Improving risk sharing scheme between public funds


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Health care reforms Structural reforms within The Agenda 2010(2002) Reducing the benefit package and increasing co-

payments

Reducing dependancy on labor costs Strengthening the self-governing bodies by organizingsupport of independent agencies (e.g. Institute forQuality and Efficiency in the Health Care System IQWiG)

Allowing selective contracts between single funds andfamily doctors or their voluntary associations insteadof collective bargaining


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Health Care Reforms The Legal Act to strengthen Competion in HealthCare (2007) Focussing competition on quality and efficiency of

care Forcing funds to offer special family doctor services

and tariffs and to bargain with family doctorsassociations

Founding a (virtual) national fund to improve the risksharing scheme by including morbidity (80

whitespread diseases with high costs of treatment) Strengthening the funds by bundling their federal

activities in one association


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Future Challenges

Medical progressDemografic change Population

Health professionals

Migration

Rural depopulation

Financial sustainability and cost containment

Ethics


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Political answers to these challenges

Strengthening primary care according tomultimorbidity and chronification

Developing population based models of family

care Improving communication, coordination,

cooperation

Investing in human resources and newtechnologies

Evaluating new primary care agreements in 2012

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