1. The german health care system

1. Obligation to insure

2. Contribution-based financing

3. Solidarity principle

4. Self-administration

• Every citizen is obligated to be insured via the statutory health insurance (gesetzliche Krankenversicherung) or via a private health insurance (only for high incomes).

• Health care is mainly financed through contributions from insured citizens and employers.

• Same care provision for everyone regardless of their contribution

• Contribution is based on the income

• Government decides on the main legal guidelines

• Implementation of these guidelines is done by the different stakeholders of the health care system

1. German state

2. Payers (health insurers)

3. Insurants

4. Health care providers

1. Ambulatory care

2. Stationary care

3. Rehabilitation

4. Logn term care (Pflege)

1. SGB V

2. SGB VI

3. SGB VII

4. SGB XI

5. SGB XII

SGB V:

Statutory health insurance (Gesetzliche Krankenversicherung)

Content

• General health care

• Rehabilitation for not-working population

SGB VI

Statutory pension insurance (Gesetzliche Rentenversicherung)

Content

• Rehabilitation for working population

SGB VII

Statutory accident insurance

(Gesetzliche Unfallversicherung)

Content

• Insurance for work related health problems

SGB XI

Long-term care insurance (Soziale Pflegeversicherung)

Content

General subvention of long-term care

SGB XII

Welfare (Sozialhilfe)

Content

• Support of non-insurants

Funding: statutory and private health insurances

statutory health insurances (SGB V)

• Ambulant and stationary medical attention

• Medication

• Sick-pay (Krankengeld)

• Hospitals

• (Independent) physicians

• Civil servants

• self employed persons

• people that exceed the upper income limit (Versicherungspflichtgrenze)

• others not obliged to be publicly insured

• Insurance rate is based on the individual risk in contrast to the statutory insurance

• Private insurers offer complementary insurances for publicly and privately insured people, e.g. supplementary dental insurance

Everybody that cannot be /is not privately insured has to be publicly insured

Main legal basis: SGB V

Fixed contribution not dependent on individual risk

• min 14.6% of a member´s earnings until the assessment ceiling of 4,687.5 per month

  • 7.3% employer

  • min 7.3% employee (insurance companies may charge an additional contribution (Zusatzbeitrag))

Funding: public (SGB XI) and private long term care insurances (Pflegeversicherungen)

Partial insurance: not all expenses are covered

Benefits depended on care level (Pflegegrad): 5 different levels since January 2017

Possible benefits:

• Care allowance (Pflegegeld) (bakim ödenegi)

• Ambulant nursing service (ambulanter Pflegedienst)

• Local residential care communities (Pflegewohngemeinschaften)

• Nursing home (Pflegeheim)

Self-administration organizations are equally occupied by representatives of the insurants and the service providers

They pass sub-legal standards to regulate individual actors.

e.g.

• range of services

• guidelines

• general agreements

• fee regulations

• fee contracts

1. Central Association of Statutory Health Insurance

   (Spitzenverband gesetzlicher Krankenversicherungen, GKV)

2. Central Association of Statutory Health Insurance Physicians

   (Kassenärztliche Bundesvereinigung, KBV)

3. Centreal Association of Statutory Health Insurance Dentists

   (Kassenzahnärztliche Bundesvereinigung, KZBV)

4. German Hospital Association

   (Deutsche Krankenhausgesellschaft, DKG)

Federal ministry of health

and

federal state ministries of health

• Institutions (Träger) of the public health care system

• Freedom of choice for patients

• Obligation to contract for the health insurance

  (Requesting persons can not be rejected)

• Principle of benefits in kind

  (all necessary expenses are paid by the health fund (no bills for the patient - in contrast to the reimbursement of costs principle ofte used by private insurances))

• No capital reserve allowed

  (capital surplus of the health insurance goes to the insurants)

• Only physicians that are members of a statutory health insurance association, registered physicians, can treat publicly insured patients (get paid for it)

• The association of the statutory health insurance physicians (Kassenärztliche Vereinigungen, KVs) negotiate the total remuneration for health services provided by their physicians with the health insurers

remuneration: ücretlendirme

negotiate: müzakerede bulunmak

• The KVs split the remuneration between their physicians

split: paylastirmak

• 17 regional KVs represented by the Central Association of Statutory Health Insurance Physicians on the federal level

• Patients have freedom of choice between registered physicians

• Only hospitals listed in the federal state hospital plan (Landeskrankenhausplan) are allowed to treat publicly insured patients (get paid for it)

federal state: federal devlet

• Hospitals close contracts with health insurers about the kind and amount of services and about budgets

(health insurers pays hospitals in exchange for contracts)

• Organized in central and state federal associations and in the German Hospital Association on the federal level

• Patients have freedom of choice between listed hospitals

• Central Association of Statutory Health Insurance Physicians

• Central Association of Statutory Health Insurance

• German Hospital Association

• Central Association of Statutory Health Insurance Dentists

• 3 neutral members

• define guidelines for the service catalog of the public health insurance

• decide measures to secure quality in ambulant and stationary care

• principal (Auftraggeber) of the Institute for Quality and Economic Efficiency in Health Care

• Compensation carried out by the KVs through the remuneration distribution scale

• In general for each quarter year the physician has a fixed amount of money to exploit

exploit: kendi cikari icin kullanmak

• Basis for the remuneration is the uniform rating scale, which defines points for services, the value of a point is not fixed but can vary from quarter to quarter

• If the physician works more than allowed by this amount, he or she gets his/her share of the leftover money from the KV for his/her region

leftover: arta kalan

case: same quarter, same patient, same health insurance

case value: total amount of money for one group of physicians/total number of cases treated by those physicians

• Case value further and further diminishes if the physician exceeds the average amount of cases per quarter of his/her group by 150%, 170% and 200%, respectively

• Billing according to scale of fees for physicians (Gebührenordnung für Ärzte, GOÄ)

• Bill is send to the privately insured patient, patient has to settle the cost transfer with his/her insurer

settle: caresine bakmak, festlegen, erledigen

• In general physicians apply the regular maximum rate (Regelhöchstsatz) of 2.3 times the basic fee (the GKV only refunds at most 1.7 times the basic fee)

regular: regulär, normal

• In complicated cases they can even go as high as 3.5 times the basic fee (Höchstsatz)

• Physicians can offer individual health services (individuelle Gesundheitsleistungen, IGel) for everyboy (patients pay himself)

The german health care system generates high costs (5298 euro per capita)

per capita: pro Kopf

Costs are increasing faster than the GNP (BIP) due to

• Agint society

• Increasing demand due to higher expectations of the consumer

• Increasing supply induced demand

• Trend to defensive medicine

Cost-cutting reform acts are only moderately succesful

Increased costs are shifted to the customer

• higher provider density (1942 hospitals with decreasing tendency and 170000 registered physicians)

• high number of medical treatments (255 hospital discharges per year and 1000 people, 18 physicians visits per year and person)

• To achieve higher profit hospitals and physicians offer more services and increase the number of patients treated

  (average time for doctor consultation: 8 min (sweden:22min))

consultation: muayene

• hospitals and physicians get less and less remuneration

• care is highly fragmented

• too many service providers with too many services offered despite limited expertise

• high variability in the quality of services also regarding well known diseases

regarding: hususunda

• no rigorous measurement of outcome quality

rigorous: özenli.titiz

• no priority on outcome

• Focus on maximizing outcome (patient value) for patients instead of minimizing costs - “Health is less expensive than sickness”

• Integration of treatments, build treatment chains connecting ambulant care, acute and rehab working together to maximize patient value

• Build Integrated Practice Units (IPU) that focus on the treatment of one disease and its implications -> gain expertise

• limit service spectra of providers

• measuring patient value for every disease and provider -> feedback for providers, decision support for patients