German Health Care System - TU Berlin · 2013. 2. 22. · German healthcare system overview Key...

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


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)


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.


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


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.


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


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 [€]


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.


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


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


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)


PPP$

Average expenditure/ hospital case (2010)

* 2009.** 2008.Source: OECD Health Data 2012.

THECOMMONWEALTH

FUND


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


Performance assessment IV

Performance assessment V

Long‐term care


Long‐term care

€ C h H I t€ Cash Home InstI 235 450 1023II 440 1100 1279III 700 1550 1550III 700 1550 1550


German Health Care System - TU Berlin · 2013. 2. 22. · German healthcare system overview Key...

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