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Self Government and Outpatient Care in

Dr. Bodo Liecker, MPHDepartment of Strategic Healthcare Management

Visit of the British Delegation

10th May 2010 in Hamburg/Germany

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Agenda

2 Self Government on Federal Level

Principles of Self Government

Pla ers

Catalogue of Benefits

u , y

3 Self Government on State Level Players

Re ional Rules of Renumeration

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1 Social Insurance

Statutory Statutory Statutory Statutory Statutory

Social Insurance

Pension

Insurance

Unemployment

Insurance

Health

Insurance SHI

Long term care

Insurance

Accident

Insurance

SHI (without administration costs): 160 bn EUR (2009)

Private Health Insurance: 25 bn EUR (2008)

Private Households: 35 bn EUR (2008)

overnmen an u c ns u ons: n

Employers: 11 bn EUR (2008)

r va e an u c ns u ons

Source: Federal Statistical Office (Apr 2010), www.destatis.de/jetspeed/portal/cms/Sites/destatis/Internet/EN/Navigation/Homepage__NT.psml

SHI data: Ministry for Health www.bmg.bund.de/, in English: www.bmg.bund.de/EN/Ministerium/ministry__node.html?__nnn=true

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Agenda

2 Self Government on Federal Level

Principles of Self Government

Pla ers

Catalogue of Benefits

u , y

3 Self Government on State Level Players

Re ional Rules of Renumeration

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2 Self Government

-

Macro-Level

Ministry of Health, overall

framework, law ("Books of

social law"

Negotiate framework/guidelines,

details and im lementationAssociations

Micro-LevelAct under the ,con ons g ven

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2 Self Government

-

Framework is given by Government and Ministry of Health

Implementation and detailing is up to self-government institutions of

sickness funds and providers

SHI in Germany is based on corporatism: health provision contractsare negotiated between the associations of sickness funds and the

assoc a ons o prov ers

Membership in associations and contracts are mandatory for singlesickness funds and single providers

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Self Government on Federal Level-

Pla ers on Federal Level In- and Out atient Care

Associations of Health Care ProvidersAssociation ofall

KBV

Funds in SHI

the regional StatutoryHealth Insurance

Ph sicians associations

DKG

GKV-

S itzenverband

KZBVHead Organisation of

German Hospital

AssociationHead Organisation

Statutory Health

Insurance

the regional Statutory

Health Insurance

Dentists associations

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Self Government on Federal Level

Pla ers on Federal Level Out atient Care

Associations ofAssociation ofall

Providers

Funds in SHI

KBVHead Organisation of

GKV-

S itzenverbandthe regional Statutory

Health Insurance

Physicians associations

Head Organisation

Statutory Health

Insurance

GKV-Spitzenverband: www.gkv-sv.de, in English: www.gkv-spitzenverband.de/Statutory_health_insurance.gkvnet

KBV: www.kbv.de

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Self Government on Federal Level

The Principles and Issues of Self Government in Outpatient Care

GKV SVHead Organisation

KBVNational Association

negotiate nationwide

a u ory ea

Insurance

a u ory ea

Insurance

Physicians

ramewor

Basic Contract Doctor-SHI and payment

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Self Government on Federal Level

-

Federal Joint Commitee

Picture by G-BA

authorised by law to issue legally binding directives

represents providers, SHI funds and patients

uses extern and impartial assesment (IQWiG)

main decision criteria are: evidence, costs/benefits and harm

Picture by Gemeinsamer Bundesausschuss: www.g-ba.de, in English: www.g-ba.de/institution/sys/english/

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Self Government on Federal Level

- " "

13 Voting Members: 5 Non Voting Members:

3 Impartial Members

Members

Patient-

Members

Provider

Members

SHI

(2 KBV)

(1 KZBV)

-

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Self Government on federal level,

Negotiating basic components of the relationship doctors - SHI

GKV SVHead Organisation

KBV

National Association

negotiate nationwide

a u ory ea

Insurance

a u ory ea

Insurance

Physicians

ramewor

Basic Contract Doctor-SHI and payment

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Self Government on Federal Level,

-

-

"Arzt-/Ersatzkassenvertrag (EKV)"autorisation for treatment

forms (e.g. prescriptions) and documentation

opening duration of doctor's practice, visits at patients homecollecting practice fees

sanctions

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Self Government on Federal Level,

Committee for Ratin Doctors Services

6 Voting Members:additional 3 Voting Impartial Members*

Members

KBV

Members

SHI

- an

reach no agreement

-

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Self Government on Federal Level,

Committee for Ratin Doctors Services

"Bewertungsausschuss"Uniform

Fee

classifies the price for each doctors service* [in points]

defines each single outpatient service*("einheitlicherBewertungs-

"

defines broad renumeration

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Self Government on Federal Level

Fee Schedule Item Service Definition of ServiceHere: tress-E

Special Accounting Rules

Number of Points

if point-value is 3,5048 Ct,Here: an additional ECG (13 250) is not allowed oc or s paymen s ,

(incl. office-rent, material,wages,...)

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Self Government on Federal Level

The Uniform Fee Shedule with Accountin Directives for ...

all Physicians General Practit ioners

+

Specialists

+,

records

care at

supplementary fees

Basic rates are graded to

special services

Basic rates are

night/weekend

emergency

the age

supplementary fee:

graded to the age

different fee items for

visit at patients

home

selected special services:

longtime ECG, spirometry...screening and early

detection

Note: accounting period is allways the quarter of the year

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Agenda

2 Self Government on Federal Level Principles of Self Government

Pla ers

Catalogue of Benefits

u , y

3 Self Government on State Level Players

Re ional Rules of Renumeration

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Self Government on State Level

Regional Players -Negotiating the regional contracts

e

vel

Landesverbnde der

Krankenkassen

KV

Association of Statutory Health

State

Negotiating Organisations

of the Health Insurance

Funds (SHI) in State

nsurance ys c ans n a e

-

Additional Services

Supply of Pharmaceuticals

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Self Government on State Level

Vereinigung (KV)

Association of Statutory

Package(members

x

(EBM- Uniform FeeShedule)

ea nsurance ys c ans

in StateDoctor

Doctor Sin le SHI FundRules for the distribution ofv

el

Single SHI FundDoctor for example: extrabudgetary/budgetaryta

te

L

Single SHI Fundn erven ons General Practitioners/

Specialists

point value adjusting

Payment: point value x pointsum(single Physician)Doctor

standardised maximumDoctor

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Self Government on State Level

Previous: SHI funds pay a overall remuneration (capitation x SHI-Members) to

KVen, based on the needs and outpatient services in 1993

- -

The overall renumeration varies analogous with the wage growth(maximum) not with the changed needs for medical services

Consequence: Pa ments do not meet the real needs

No compatibility with the new financial terms (morbidity adjusted riskstructure compensation scheme, Gesundheitsfonds (health care stock))

Future: Payment will depend on patient's state of health

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Self Government on State Level

calculated

Vereinigung (KV)

Association of Statutory

(EBM- Uniform Fee

Shedule)

Individual needsof each insured

xea nsurance ys c ans

in StateDoctor

Doctor Sin le SHI FundRules for the distribution ofv

el

Single SHI FundDoctor for example: extrabudgetary/budgetaryta

te

L

Single SHI Fundn erven ons General Practitioners/

Specialists

point value adjusting

DoctorPayment: merits in

(single physician)up to individual standardised

Doctor

maximum (depending on

morbidity)

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Thank you for your attention!

www. -on ne. e