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Remuneration of Health Care Providers in Germany
Each year the national associations of sickness funds negotiate agreements
with the national associations of sickness-funds physicians. The same
bargaining procedures apply to dental care. The associations work with
guidelines suggested by the Advisory Council for the Concerted Action
in Health Care and establish umbrella agreements on guidelines for the
delivery of medical care and fee schedules tied to the relative value
scales of about 2,000 medical procedures. At the national level, the Federal
Committee of Sickness Funds Physicians and Sickness Funds is a key player,
although it is little known outside the circle of health care practitioners
and experts. It sets spending limits on the practice of medicine in physicians'
offices, determines the inclusion of new medical procedures and preventive
services, adjusts the remuneration of physicians, and formulates guidelines
on the distribution and joint use of sophisticated medical technology
and equipment by ambulatory-care or office-based physicians and hospital
physicians.
At the regional level, regional associations of sickness funds and regional
associations of sickness-funds physicians negotiate specific contracts,
including overall health budgets, reimbursement contracts for all physicians
in a region, procedures for monitoring physicians, and reference standards
for prescription drugs.
A key instrument for containing GKV health care costs is the global budget,
introduced in the mid-1980s, which sets limits on total health care expenditures.
The GSG of 1993 retained cost containment methods until 1996, when it
is hoped that structural reforms will no longer make it necessary. By
means of the global budget, regional increases in total medical expenditures
are linked to overall wage increases of sickness-funds members. The sickness
funds transfer monies amounting to the negotiated budget to the regional
associations of sickness-funds physicians; the associations pay their
members on the basis of points earned from services performed in a billing
period. The value of the services is determined by the negotiated fee-for-service
schedule, which assigns points to each service according to the relative
value scale. No exchange of money occurs between sickness-fund patient
and physician. Privately insured patients pay their physicians themselves
and are reimbursed by their insurance companies.
The monetary value of a point is determined by dividing the total value
of points billed by all sickness-funds physicians into the region's total
negotiated health budget. A greater than expected number of services billed
will mean that a point has less value, and a physician will earn less
for a particular service than in a previous year. To prevent physicians
from attempting to earn more by billing more services, committees of doctors
and sickness funds closely scrutinize physician practices. Excess billing
practices are easily detected by means of statistical profiles of diagnostic
and therapeutic practices that identify departures of individual doctors
from the group average (a form of community rating). Physicians found
guilty of improper conduct are penalized. The same procedures apply to
dentists.
Land hospital associations and Land associations of
sickness funds negotiate the general standards for hospital care and procedures
and criteria by which to monitor the appropriate and efficient delivery
of medical care. Each hospital negotiates a contract on hospital care
and the prices for hospital services with the regional sickness-funds
association. Until 1993 hospitals' operating costs (of which salaries
made up as much as 75 percent) were covered by per diem rates paid by
public and private insurance. Hospital investments and equipment are financed
by Land general revenues.
The GSG of 1993 developed a more sophisticated reimbursement method for
hospitals than the simple per diem rate in an attempt to achieve greater
hospital efficiency and thereby reduce costs. The law requires that four
sets of costs be negotiated for each hospital: payments to diagnosis-related
groups for the full treatment of a case, with the possibility of an extra
payment if a patient is hospitalized for an unusual length of time; special
payments for surgery and treatments before and after surgery; departmental
allowances that reimburse the hospital for all nursing and medical procedures
per patient per day; and finally a basic allowance for all non-medical
procedures and covered accommodations, food, television, and similar expenses.
The law also introduced new aggregate spending targets and spending caps
on hospitals for the period 1993 to 1995. Moreover, the law imposes more
stringent capital spending controls on hospital construction and expensive
medical equipment.
* Development of
the Health Care System
* Health Insurance
* Health Care Providers
* Remuneration
of Health Care Providers
* Current Health Care
Issues
- Population
- Immigration
- Women In Society
- Marriage
- Fertility
- Mortality
- Age-Gender Distribution
- Social Structure
- Health Care
- Religion
- Urbanization
- Geography (lands,
topography and climate)
- Society (population,
religion, marriage, urbanization, social structure, immigration)
- Education (elementary,
junior, senior, vocational, higher)
- Economy (the Economic
Miracle, financial system, Bundesbank, business culture)
- Politics (government,
the Chancellor, the President, parties, Bundestag)
- Mass Media (newspapers,
radio and TV)
- Armed Forces (army,
navy, air forces, police)
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