The German Health Care System –Organization, Financing, Reforms, Challenges ...
Prof. Dr. Reinhard BusseProf Dr Jürgen WasemProf. Dr. Jürgen Wasem
| Presentation to DG Sanco | Brussels, February 20, 2013 |
Thi d t“Risk-structurecompensation”
The German system at a glance
Ca. 140 sickness fundsThird-party payerscompensation
Collector of resources Health fund
Uniform wage-related contribution+ possibly additional premium
Ca. 45 private insurersHealth fund
S+ possibly additional premium (set by sickness fund), Contracts,
mostly collective
StrongdelegationRisk-related premium
Choice of fund/insurer
mostly collectiveNo contracts
g(Federal Joint Committee)
& limitedgovernmental control
Population ProvidersU i l Choice
g
pUniversal coverage:
Statutory Health Insurance 86%
Public-private mix,organised in associations
b l t / h it l
Choice
Insurance 86%, Private HI 10%
ambulatory care/ hospitals
| Presentation to DG Sanco | Brussels, February 20, 2013 |
German healthcare system overview
Key characteristics:
a) Sharing of decision‐making powers between the sixteen Länder(states), the federal government and statutory civil society
i tiorganizationsi.e. important competencies are legally delegated to membership‐based, self‐regulated organisations of payers and providers g g p y p
b) German health care [almost] = Statutory health insurance (SHI)SHI Cornerstone of health service provision is the Fifth Book of the German Social Law (SGB V) i e it organi es and defines the self reg lated “corporatist” str ct res andi.e. it organizes and defines the self‐regulated “corporatist” structures and give them the duty and power to develop benefits, prices and standards
c) Existence of substitutive private health insurance alongside SHI| Presentation to DG Sanco | Brussels, February 20, 2013 |
German healthcare system overview
Key characteristics:
d) Sectoral bordersProvision of ambulatory and inpatient services. y pPlanning, resource allocation, provision and financing are separate for ambulatory (office‐based physicians) and inpatient (hospitals) sector.
Complicates the provision of health care delivery (problematic especially for chronically ill answers: Disease Management (p p y y gProgrammes and selective “integrated care” contracts)Increases the amount of specialists h h l h dIncreases the health care expenditure
Various reforms have tried to lessen sectoral borders (last in 2012 by Various reforms have tried to lessen sectoral borders (last in 2012 by creating a new in‐between sector for highly specialized ambulatory care)
| Presentation to DG Sanco | Brussels, February 20, 2013 |
C lib R d G d li i C lib ... in the old times Cons.‐lib. Red‐green Grand coalition Cons.‐lib. 1994/95 1996/97 2004 2007 2009 2011
Compulsory insurance
Mandatory only for employed/pensioners/unemployed up to certain income
Universal coverage in SHI (or PHI, from 2009) Selective contracts forChoice
between SHI and PHI
For employed above certain income within 1 year … for 3 years … within 1 year
Choice of SHI For certain professional groups For most insured (97%) For all insured except farmers
Selective contracts for integrated care (2000); financially incentivized
2004-08, but only ~0.3%fund only Financial contribution
Contribution rate differing among sickness funds Uniform rate plus possibly add’l premium set by sickness fund Mergers between
2004 08, but only 0.3% of total expenditure
Actual amount capped at 1%
Tax subsidy if add’l premium >2%
i k l d i i i bidi f 80
Mergers between different fund types
allowed; sickness fund associations FederalRisk‐structure
compensation None; pooled expenditure for pensioners
Risc structure compensa‐tion based on age and sex
+ DMPs as criterion & high‐cost pool
+ morbidity from 80 diseases ‐ DMP/ high‐cost pool
Contents of Relatively uniform but freedom for Dental care Palliative Almost uniform (only 0.7% of
associations Federal Association (2008)
N l i bbenefit package
additions by sickness funds for adults excluded (until 1999)
care incl.; OTC drugs excl.
exp. for additions by sickness funds)
Decisions on Sectoral decisions G‐BA responsible across sectors
No claim bonus, deductibles, additional
benefits … in SHI insurance allowedbenefits Not evidence‐based HTA for
ambulatory services
Drug benefit eval.; IQWiG founded
+ Cost‐benefit assessment of drugs
+ early benefit eval. of all new drugs
insurance allowed
C lib R d G d li i C lib ... in the old times Cons.‐lib. Red‐green Grand coalition Cons.‐lib. 1994/95 1996/97 2004 2007 2009 2011
Compulsory insurance
Mandatory only for employed/pensioners/unemployed up to certain income
Universal coverage in SHI (or PHI, from 2009) Selective contracts forChoice
between SHI and PHI
For employed above certain income within 1 year … for 3 years … within 1 year
Choice of SHI For certain professional groups For most insured (97%) For all insured except farmers
Selective contracts for integrated care (2000); financially incentivized
2004-08, but only ~0.3%fund only Financial contribution
Contribution rate differing among sickness funds Uniform rate plus possibly add’l premium set by sickness fund Mergers between
2004 08, but only 0.3% of total expenditure
Actual amount capped at 1%
Tax subsidy if add’l premium >2%
i k l d i i i bidi f 80
Mergers between different fund types
allowed; sickness fund associations FederalRisk‐structure
compensation None; pooled expenditure for pensioners
Risc structure compensa‐tion based on age and sex
+ DMPs as criterion & high‐cost pool
+ morbidity from 80 diseases ‐ DMP/ high‐cost pool
Contents of Relatively uniform but freedom for Dental care Palliative Almost uniform (only 0.7% of
associations Federal Association (2008)
N l i bbenefit package
additions by sickness funds for adults excluded (until 1999)
care incl.; OTC drugs excl.
exp. for additions by sickness funds)
Decisions on Sectoral decisions G‐BA responsible across sectors
No claim bonus, deductibles, additional
benefits … in SHI insurance allowedbenefits Not evidence‐based HTA for
ambulatory services
Drug benefit eval.; IQWiG founded
+ Cost‐benefit assessment of drugs
+ early benefit eval. of all new drugs
insurance allowed
Decision‐making in German SHI
Federal Ministry of HealthLegislation
ParliamentSupervision
Patient
150,000 ambulatory care
Federal Association of SHI
German Hospital Federation
2,100 hospitalsambulatory care physicians and
psychotherapists
Association of SHI Physicians (KBV)
Federation (DKG)
Federal Association f Si k F d
140 sickness funds
of Sickness Funds
Federal Joint Commitee (G-BA)( )
Members: 13 voting – 3 neutral + 5 sickness funds + 5 providers(+ up to 5 patient representatives)
Statutory Health Insurance| Presentation to DG Sanco | Brussels, February 20, 2013 |
Objectives of Federal Joint Committee
Main functions: to regulate SHI‐wide issues of access, benefits and quality (and not primarily of costs or expenditure).a d qua ty (a d ot p a y o costs o e pe d tu e).
Normative function of the G‐BA by legally binding directives(“sub‐law“) to guarantee equal excess to necessary and ( ) g q yappropriate services for all SHI insured.
Benefit‐package decisions must be justified by an evidence‐p g j ybased process to determine whether services, pharmaceuticals or technologies are medically effective in terms of morbidity, mortality and quality of life.
By law, evidence based assessments can only be used to select the most appropriate (efficient) service etc. from others – not to prioritize among service areas: if a costly innovation has a significant additional benefit the sickness funds must pay for itsignificant additional benefit, the sickness funds must pay for it.
| Presentation to DG Sanco | Brussels, February 20, 2013 |
Federal Joint Committee: preparation of decisions
Decisions are prepared by 9 sub‐committees: Pharmaceuticals Quality Assurance Disease management programs
M th d l i l E l ti (i l i f b l t Methodological Evaluation (inclusion of new ambulatory care services in benefit basket; NB: in hospitals, services can only be excluded))
Highly specialized ambulatory care (by office‐based physicians and hospitals; new sector since 2012)
Referred Services (rehabilitation, care provided by non‐physicians, ambulance transportation etc.)
Needs based Planning (ambulatory care; NB: hospital Needs‐based Planning (ambulatory care; NB: hospital capacities are planned by state governments)
PsychotherapyPsychotherapy Dental Services
| Presentation to DG Sanco | Brussels, February 20, 2013 |
Federal Joint Committee: support through institutes
Federal Ministry of HealthLegislation
ParliamentSupervision
Patient
Federal Association of SHI
German Hospital Federation
2,100 hospitals150,000 ambulatory care Association of SHI
Physicians (KBV)Federation
(DKG)
Federal Association f Si k F d
140 sickness funds
ambulatory care physicians and
psychotherapists
of Sickness Funds
Federal Joint Commitee (G-BA)( )
Institute for Quality and Efficiency in Healthcare (IQWiG) – technologies
AQUA Institute for Quality – focused on providers( ) g p
Statutory Health Insurance| Presentation to DG Sanco | Brussels, February 20, 2013 |
Expenditure control
No overall expenditure limit or cap – but since 1970s legal requirement for “income‐oriented“ expenditure growthrequirement for income oriented expenditure growth.
In 1990s main – legally required – instruments: sectoral budgets (ambulatory, dental, hospitals) and capsbudgets (ambulatory, dental, hospitals) and caps (pharmaceuticals), growing in line with contributory income of insured.
Since 2001 (pharmaceuticals), 2005 (hospitals) and 2009 (ambulatory care) more flexible arrangements trying to balance need and expenditure control greater role for contract partners to negotiate volumes;
but legislator is intervening time after time, especially in times of financial deficittimes of financial deficit.
| Presentation to DG Sanco | Brussels, February 20, 2013 |
Expenditure as % of GDP has been stable over long periods (unlike e.g. in NL or DK) but reunification and recession in 2009 were major forces for increases
| Presentation to DG Sanco | Brussels, February 20, 2013 |
| Presentation to DG Sanco | Brussels, February 20, 2013 | | Source: Buchner/ Göppfarth/ Wasem, Health Policy 2013 |
Financial flows (2011)
| Presentation to DG Sanco | Brussels, February 20, 2013 | | Source: Göppfarth & Henke, Health Policy 2013 |
Financial contribution (employee part only)
74.25€
tion
[€] 60€
Uniform by law8.2%
20€
cont
ribu
40€
3712 50€
mon
thly
c
20€
3712.50€
m
If average additional premium >2% of income:“Subsidy“ in form of lower contribution ratey
monthly income [€]
| Presentation to DG Sanco | Brussels, February 20, 2013 |
| Presentation to DG Sanco | Brussels, February 20, 2013 | | Source: Buchner/ Göppfarth/ Wasem, Health Policy 2013 |
Both the Health fund as well as the sickness funds can have higher or lowerBoth the Health fund as well as the sickness funds can have higher or lower revenue and expenditure than ex-ante calculated: e.g. in 2009, the Health Fund‘s revenue fell short due to the fincial crisis while in the following years it was higher
than predicted due to the booming economy in Germany.
| Presentation to DG Sanco | Brussels, February 20, 2013 |
p g y y
| Source: Göppfarth & Henke, Health Policy 2013 |
The ambulatory care sector
ca. 145.000 physicians, of which ca. 130.000 self-employed
ca. 83.000 single-handed practices (79%)ca. 83.000 physicians (58%)p y ( )
ca 20 500 group practices (19%)ca. 20.500 group practices (19%)ca. 51.500 physicians (36%)
Mandatoryca. 1.750 health centers (2%)ca. 9.500 physicians (6%)
ymembership in 17 regional
i tiassociations
| Presentation to DG Sanco | Brussels, February 20, 2013 |
Sickness fund X2‐step payment of ambulatory care physicians
Sickness fund Y Sickness fund ZSickness fund Y Sickness fund ZCapitation based on previous year‘s utilisation, increase factor, adjustments
Physicians‘ association (KV)Physicians association (KV)
GP budget Specialists‘(ca. 1/3) budget (ca. 2/3)
Capped FFS (e g specialty specific case volume age based caps for basic (RLV) and groups ofspecial services (QZV))
Capped FFS (e.g. specialty-specific case-volume age-based caps for basic (RLV) and groups of
GP 1 Spec1GP 2 GP 3 Spec2 Spec3| Presentation to DG Sanco | Brussels, February 20, 2013 |
The hospital sector: many beds, many cases
900Acute care hospital beds per 100000
800
700AustriaBelgiumCzech RepublicDenmark
500
600DenmarkFranceGermanyNetherlandsPolandSwedenSwitzerland
400
SwitzerlandUnited KingdomEU members before May 2004 EU members since 2004 or 2007
300
2001980 1990 2000 2010
| Presentation to DG Sanco | Brussels, February 20, 2013 |
Payment of inpatient care
Operating costs (NB: investment costs are covered through taxes by the Länder)
Sickness funds negotiating activity based DRG budgets every year with every‐ Sickness funds negotiating activity based DRG budgets every year with every “planned” Hospital
Casemix X
Base rate
Supplementary fees Hospital budget +=
Extra‐budgetary
payments (e.g. +‐ Budget over‐run adjustment (hospital pays back):
Base rate p y ( gfor innovations)
Budget over run adjustment (hospital pays back): • 65 % (standard DRGs), 25 % (drugs, medical, polytrauma and burns DRGs),
Negotiation for hardly predictable DRGs
‐ Budget under‐run adjustment (hospital receives compensation): • 20% (standard DRGs)• 20% (standard DRGs)
| Presentation to DG Sanco | Brussels, February 20, 2013 |
PPP$
Average expenditure/ hospital case (2010)
* 2009.** 2008.Source: OECD Health Data 2012.
THECOMMONWEALTH
FUND
| Presentation to DG Sanco | Brussels, February 20, 2013 |
Pharmaceutical policies: evaluation and reimbursement
| Presentation to DG Sanco | Brussels, February 20, 2013 | | Source: Henschke/ Sundmacher/ Busse, Health Policy 2013 |
Pharmaceutical policies: evaluation and reimbursement
Performance assessment I
Physician density by region and patient access by income
300 worse
Performance assessment II
200
250in
e)
150AT
DK
FRman
y (r
efer
ence
li
In-hospital letality
Diabetes
100IT
NL
CH
GBdevi
atio
n in
Ger
m
StrokeCOPD
0
50 GB
US
perc
enta
ge d
AMI
‐50 Asthma
‐100better
„Ambulatory care-sensitive conditions“
Performance assessment III
Avoidable mortality
Deaths per 100,000 population*
134 127
120
150 1997–98 2006–07
Deaths per 100,000 population
88 89 8899 97
109 116
106 97
115 113 120
100
76 88 89
81 88
55 57 60 61 61 64 66 67 74 76 77 78 79 80 83 96 50
55
0 FR AUS ITA JPN SWE NOR NETH AUT FIN GER GRE IRL NZ DEN UK USFR AUS ITA JPN SWE NOR NETH AUT FIN GER GRE IRL NZ DEN UK US
| Presentation to DG Sanco | Brussels, February 20, 2013 |
Performance assessment IV
Performance assessment V
Long‐term care
| Presentation to DG Sanco | Brussels, February 20, 2013 |
Long‐term care
€ C h H I t€ Cash Home InstI 235 450 1023II 440 1100 1279III 700 1550 1550III 700 1550 1550
| Presentation to DG Sanco | Brussels, February 20, 2013 |
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