El sistema sanitario de Alemania: Características, retos, reformas

Sophia Schlette, MPH Encuentro, Madrid, 13 febrero 2013

Distintos o parecidos?

The Bismarck Model •Germany

•Belgium

•(France)

•Japan

•(Switzerland)

•USA: employer-related group insurance

The Beveridge Model •UK

•Scandinavian countries

•Spain

•Italy

•Cuba

•USA: VA, Indian Health Service

The national health insurance model •Austria

•Canada

•South Korea

•Taiwan

•USA: Medicare

The OOP model •Cambodia, Burkina Faso, some states of India…

•50 mio uninsured in the U.S.

Retos y reformas similares…

US ACA Triple Aim 2010:

• Better health

• Better care

• Lower cost

Desafíos en Alemania 2002-2010:

• Cost containment

• Care coordination

• Quality (and transparency)

Características del sistema sanitario alemán

• Basado en el principio de la solidaridad

– Cotizaciones según capacidad de pago (base salarial)

– Subsidios múltiples (healthy pay for sick, young for old, men for women, wealthy subsidize poor, singles subsidize families)

– Acceso universal

– Cobertura universal obligatoria

– Muchas posibilidades de elección

Los logros

• Buen acceso

• Cobertura universal y generosa

• Medicina de punta

• Sistema valioso: rango 6 por gasto PIB

para salud, 5 o 6 por gasto p.c.

• Moderación del gasto

International Comparison of Spending on Health, 1980–2008

Average spending on health per capita ($US PPP)

Total expenditures on health as percent of GDP

Source: Commonwealth Fund, OECD Health Data 2010 (June)

Health Spending per Capita, 2009 Adjusted for Differences in Cost of Living

* 2008.

Source: Commonwealth Fund, OECD Health Data 2011 (June 2011).

% GDP

Dollars

Los retos

Sectores y silos

• Separación hospital-ambulatorio-social

• Presupuestos siguen sectores

• 2 sistemas tarifarios

• 2 sistemas de medida de calidad

• 2 sistemas de seguro de salud

• Divisiones profesionales

• 2 tipos de ingresos: salarios vs. FFS

• Competencias centrales, regionales y locales

• Códigos sociales poco alineados

Dónde están los médicos?

Physicians per 100.000 pop 135,6 - 143,8 143,9 - 152,9 153,0 - 157,0 157,1 - 160,8 160,9 - 163,1 163,2 - 174,9 175,0 - 176,7 176,8 - 232,0 232,1 - 239,5 239,6 - 244,4 Year: 2010 All ambulatory care physicians per Bundesland

© 2013 versorgungsatlas.de

Physician-patient contacts 15,3 - 15,9 16,0 - 16,6 16,7 - 17,3 17,4 - 18,0 18,1 - 18,9 Year: 2007 All sexes All ambulatory care physicians per Bundesland

© 2013 versorgungsatlas.de

Falta de coordinación entre especialista y médico de familia

Medicamentos

Información crítica

Notificación médico cabecera en emergencias

Retos complejidad y alineamiento

• Muchos actores, muchas instituciones, muchos intereses

• Muchos médicos pero disparidades regionales pronunciadas

• Uso excesivo, insuficiente y mal uso de servicios sanitarios,

creciente volumen de servicios

• Poca utilización de HIT en la gestión clínica o a nivel de población

• Transformaciones en los recursos humanos: envejecimiento,

feminización, expectativas hacia work-life-balance

• Inercia, complacencia y poca curiosidad innovadora

Abordando los desafíos: qué hemos hecho?

… and the responses 1988-2010-??

Year passed Name of legislation 1988 Health Care Reform Act of 1989

1992 Health Care Structure Act of 1993

1994 Social Code Book XI (Statutory Long-Term Care Insurance)

1996 Health Insurance Contribution Rate Exoneration Act

1997 First and Second Statutory Health Insurance Restructuring Acts

1998 Act to Strengthen Solidarity in Statutory Health Insurance

1999 Statutory Health Insurance Reform Act of 2000

Act to Equalize Statutory Provisions in SHI 2001

2000 Infection Protection Act

2001 Social Code Book IX (Rehabilitation)

Reference Price Adjustment Act

Pharmaceutical Budget Redemption Act

Act to Reform the Risk Structure Compensation Scheme in SHI

Act to Newly Regulate Choice of Sickness Funds

2002 Pharmaceutical Expenditure Limitation Act

Case Fees Act

Contribution Rate Stabilization Act

2003 Twelfth Social Code Book V Amendment Act

First Case Fees Amendment Act

Statutory Health Insurance Modernization Act

2004 Act to Adjust the Financing of Dentures

Second Case Fees Amendment Act

2007 Statutory Health Insurance Competition Strengthening Act

2008 Long-Term Care Insurance Reform

2009 Care Structures Act

2010 Pharmaceutical Market Restructuring Act

Medidas y remedios en los 80 y 90: entre solidaridad y competición

• 1980s-90s: Enfoque en costos, moderación de los

gastos y estabilidad de cotizaciones

• 1990s: Pasos hacia la competencia entre

aseguradoras públicas (level playing field),

elección, proyectos pilotos en coordinación,

introducción del seguro de dependencia

Reformas estructurales 2000-2008: hacia calidad y transparencia

2000-2008 Legislación accelerada y sistemática hacia

• Coordinación de servicios: incentivos para GP gatekeeping,

DMPs, contractos de integración, policlínicas/centros de

salud, LTC one-stop-shops

• transparencia: medida de calidad obligatoria (sector

hospitalario) public reporting, patient engagement

• eficiencia: value-based purchasing

• Reformas estructurales: centralización de la toma de

decisiones, evidence-based decision making

Reformas estructurales: Centralizando la toma de decisiones

2004 Federal Joint Committee (www.g-ba.de)

2004 Institute for Quality and Efficiency in

Health Care (www.iqwig.de)

2009 Health Fund

[Políticas desde 2009]

• Acceso accelerado a innovaciones (AMNOG)

• Eliminación de incentivos hacia la coordinación

• Reforma de la planificación de capacidades

• Fortalecimiento del GBA

• Delegación de competencias del GBA hacia los

Länder

• Vacío de liderazgo estratégico

Auto-gestión en el sistema de salud alemán Autoridad entre el Estado y la Sociedad Civil

Government Parliament

Federal Joint Committee (GBA)

statutory health insurers

provider organizations

citizen physician

dentists

hospital

Legal framework

Delegation of authority and tasks

Self-governance

Civil Society

consultation

•patient (choice) •provider

•electorate (voice)

State

•member •representation •member (choice)

•contract

Federal Joint Committee aka G-BA (Gemeinsamer Bundesausschuss)

5 patient representatives

can file motion, cannot vote

5

Provider

representatives

5

SHI

representatives

Impartial Chairman

2 impartial chair members

13 voting members

Federal Joint Committee

§ 91 SGB V

Revised voting rights

since 1/12

El Fondo Sanitario

Financiamiento desde el 2009

14

Health Fund (100%)

Employees/Insured (49%)

Employers (48%)

Taxes (~ 3%)

Morbidity-adjusted

allocations Sickness

funds Sickness

funds Sickness

funds Sickness

funds Sickness

funds Sickness

funds 145

Sickness funds

Additional flat premiums /

Bonus payments

El impacto de las reformas estructurales 2002-2009

“The First Law of Improvement”

Every system is perfectly designed to achieve exactly

the results it gets.

Uwe Reinhardt, Princeton

Impacto sobre las aseguradoras públicas I

Foundations remain untouched:

• Solidarity principle

• Choice of 144 sickness funds (nonprofit)

• Family insurance

• Contribution-based financing

• Opting out-option toward PHI remains

Impacto sobre las aseguradoras públicas II

• Contribution rate set by Gvt (15.5%) – Shared employer/employee (7,3%/8,2%) contributions – Income cap of 44.100 € p.y. / 3.675 Euro p.m. – Contributions go to Health Fund, and are then allocated to

insurers based on population risks

• SF can raise community-rated supplementary premiums, or pay out surplus to SHI members

• Tax funding: 4 billion € in 2009 to be increased successively by 1,5 billion €/year till reaching 14 billion/year

• PHI to offer standard benefit package to all new clients

Impacto sobre los servicios de salud

• Financial incentives for care coordination • Political endorsement for primary care • New contractual freedoms, easing horizontal

integration and cooperation: – integrated care contracts – medical care centers – ambulatory surgery in small clinics – hospital outpatient care at polyclinics…

• New mandatory offers: Disease Management Programs

• Enhanced public reporting on outcome measures de los hospitales

Impacto sobre los servicios de salud: aumentan contratos de integración

Source: BQS Register 140d, 30th June 2008

Impacto sobre los servicios de salud: aumentan centros de salud

Source: KBV. Entwicklung der Medizinischen Versorgungszentren aktuell. 11/2011

“House of Health” Berlin-Alexanderplatz

50 Physicians

22 Specialties

Salary-based

• DMPs for six conditions - Diabetes type I & II

- CHD

- COPD

- Asthma

- Breast cancer

• Specific requirements for care targets, drugs, documentation

• Certification by Federal Insurance Authority, run by every SF

• 5,9 million enrolled patients, 48% in diabetes II DMPs (2011)

• Large scale evaluations show positive effects on care quality, fewer hospitalizations, higher patient satisfaction, quality of life

Impacto sobre los servicios de salud: condiciones crónicas

Impacto sobre transparencia (toma de decisiones y calidad)

• Federal Joint Committee holds monthly plenaries in public

• Patient groups have observatory status on GBA

• Public reporting - every hospital must publish outcome quality data

• Rankings are being published and search engines allow to screen providers based on criteria and services (www.weisse-liste.de)

• Quality measures and QI in ambulatory care harder to do, not aligned with inpatient care

De aquí en adelante: nuevas herramientas para nuevos desafíos?

• Sistemas de pago

• Flexibilización de contratos y modelos de prestación

• Gestión de poblaciones

• Orientación hacia el paciente

• Calidad & coordinación

• Trabajo en equipo multiprofesional

• Solidaridad

• “Going Dutch”: Rol de las aseguradoras privadas

Lecciones?

• “Governance” doesn’t mean “government take-over”

• Self-governance is actually a smart thing

– A ‘little lawmaker’ avoids political interference and political instability

– At best it can build trust among payers, providers, and patients

• Payers need to become competitive, smart purchasers

• Why data: What isn’t measured won’t get changed

• Quality measures need to be aligned across settings

• Governance reform needs bipartisan support, windows of opportunity

• Governance reform needs good PR and transparent communication

• No pain point, no reform…

• No quick fixes

“The patient is the boss; we are the servants. They, not others, should direct their own care, and the doctors, nurses, and hospitals should know and honor what the patient wants.”

Don Berwick

Back ups

• OECD Health Data 2011

• Commonwealth Fund International Health Policy Surveys

• Sachverständigenrat Sondergutachten 2012

Further readings

• Blum, Kerstin. "Care coordination gaining momentum in Germany". Health Policy Monitor, July 2007. Available at www.hpm.org/survey/de/b9/1

• Busse, Reinhard. The health system in Germany. Eurohealth 14(2008)1

• Lisac, Melanie. "Health care reform in Germany: Not the big bang". Health Policy Monitor, November 2006. Available at www.hpm.org/survey/de/b8/2

• Lisac, Melanie, Henke, K.-D., Reimers, L., Schlette, S. Access and Choice – Competition under the Roof of Solidarity in German Health Care. An analysis of health policy reforms since 2004. Article accepted for publication, Health Policy, Economics, and Law, forthcoming.

• Schlette, Sophia, Lisac, M., Blum, K.. Integrated Primary Care in Germany – The road ahead. Article accepted for publication, International Journal on Integrated Care, forthcoming

• Melanie Zimmermann, reviewers: Reinhard Busse, Sophia Schlette. "Health financing reform idea: health fund". Health Policy Monitor, June 2006. Available at www.hpm.org/survey/de/b7/1

Aseguradoras de salud en Alemania

Population: 82.5 million

Aseguradoras públicas (144 entidades)

• Ambito de cobertura

– Prevención

– Hospital (Copay: € 10/day)

– Servicios ambulatorios (Copay: € 10/quarter)

– Libre selección de médicos de familia y especialistas

– Prescripciones (Copay: € 5-10/script)

– Salud mental, salud dental

– Rehabilitación &

– Compensación de ingresos

Aseguradoras privadas (47 entidades)

– Seleción de riesgos

– Individual underwriting

– Beneficios definidos por contrato (hay requerimientos minimos)

– Acceso privilegiado, tarifas superiores para médicos

• Quien es eligible? – Auto empleados, por cuenta propria

– Funcionarios del estado, de entidades públicas

– Ingresos altos (> € 49 500 / year)

• In teoría 20% de la poblacion, en práctica 75% se quedan en el sistema público

• Decisión para cobertura privada “via única”

Aseguradora pública

Paciente médico

Asociación Regional de

médicos Remuneración global

ajustada

Distribución de remuneración FFS

(pago por servicio no cubierto)

Pago de médicos en Alemania: Contratos colectivos regionales

Overall Remuneration

►Paid by sickness funds to regional physician associations

►Consists of a budgeted component (morbidity-based overall remuneration MLV) and a non-budgeted component (fee-for-service ELV)

►Negotiated between regional physician associations and regional associations of sickness funds

► Increase based on changes in morbidity (Reference Conversion Factor – Orientierungspunktwert)

►Gov’t intervened for 2011 and 2012: Increase restricted to 1.25 %

Distribution of Remuneration

►Physician remuneration based on a fee-for-service basis

►Uniform Value Scale (EBM)

►Bundled Elements

►Payment = Relative Value x Conversion Factor

►Conversion Factor = Reference Conversion Factor +/- Regional Correction

►Reference Convergence Factor negotiated by Physician Payment Commission – Bewertungsausschuss) between Federal Association of Sickness Funds and Federal Association of Physicians’ Associations

►Change based on changes in morbidity

Cost Control Mechanisms

►The Overall Remuneration is broken down to the individual practice level

►Standard Service Volume (SSV) = Case Value of Speciality x No. of Cases x Age Adjustment

►Physicians get full payment within the SSV, and reduced payments for volume above the SSV

►Physician Associations have to hold back overall remuneration for payments above SSV

►Efficiency review for prescriptions ► In theory, physicians are liable for non-efficient prescriptions

Pago de médicos: Discontento pese a aumentos

Source: National Association of Statutory Health Insurance Funds

German Health Care System Organizational Chart of Key Players

Federal Ministry of Health

Federal Parliament

Physicians Hospitals

Institute for Quality and Efficiency

17 Regional Physician

Associations

Federal Association of SHI Physicians

16 Regional Hospital

Associations

German Hospital Association

Sickness Funds

Accredited Patient Organizations

Insured Patients

Federal Joint Committee

State Ministries of

Health

Free to choose Free to choose

Choice

Nonvoting

Pharmaceuticals

• All registered prescription drugs covered – Co-pay of € 5-10/ script (no tiered co-payment system)

– Co-pay waivers for small children & chronically ill

– Co-pay waivers for “low priced” drugs (<70% reference price)

– Second opinion needed for expensive drugs

• Lifestyle drugs not covered (ie. Viagra)

• OTC drugs not covered (few exceptions)

• Pharmacy profit margins fixed by law: € 8.10 + 3%

• No manufacturer price limits, but reimbursement

ceilings within drug categories

• Generic prices higher than U.S. or other EU