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Self Government and Outpatient Care in
Dr. Bodo Liecker, MPHDepartment of Strategic Healthcare Management
Visit of the British Delegation
10th May 2010 in Hamburg/Germany
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Agenda
2 Self Government on Federal Level
Principles of Self Government
Pla ers
Catalogue of Benefits
u , y
3 Self Government on State Level Players
Re ional Rules of Renumeration
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1 Social Insurance
Statutory Statutory Statutory Statutory Statutory
Social Insurance
Pension
Insurance
Unemployment
Insurance
Health
Insurance SHI
Long term care
Insurance
Accident
Insurance
SHI (without administration costs): 160 bn EUR (2009)
Private Health Insurance: 25 bn EUR (2008)
Private Households: 35 bn EUR (2008)
overnmen an u c ns u ons: n
Employers: 11 bn EUR (2008)
r va e an u c ns u ons
Source: Federal Statistical Office (Apr 2010), www.destatis.de/jetspeed/portal/cms/Sites/destatis/Internet/EN/Navigation/Homepage__NT.psml
SHI data: Ministry for Health www.bmg.bund.de/, in English: www.bmg.bund.de/EN/Ministerium/ministry__node.html?__nnn=true
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Agenda
2 Self Government on Federal Level
Principles of Self Government
Pla ers
Catalogue of Benefits
u , y
3 Self Government on State Level Players
Re ional Rules of Renumeration
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2 Self Government
-
Macro-Level
Ministry of Health, overall
framework, law ("Books of
social law"
Negotiate framework/guidelines,
details and im lementationAssociations
Micro-LevelAct under the ,con ons g ven
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2 Self Government
-
Framework is given by Government and Ministry of Health
Implementation and detailing is up to self-government institutions of
sickness funds and providers
SHI in Germany is based on corporatism: health provision contractsare negotiated between the associations of sickness funds and the
assoc a ons o prov ers
Membership in associations and contracts are mandatory for singlesickness funds and single providers
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Self Government on Federal Level-
Pla ers on Federal Level In- and Out atient Care
Associations of Health Care ProvidersAssociation ofall
KBV
Funds in SHI
the regional StatutoryHealth Insurance
Ph sicians associations
DKG
GKV-
S itzenverband
KZBVHead Organisation of
German Hospital
AssociationHead Organisation
Statutory Health
Insurance
the regional Statutory
Health Insurance
Dentists associations
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Self Government on Federal Level
Pla ers on Federal Level Out atient Care
Associations ofAssociation ofall
Providers
Funds in SHI
KBVHead Organisation of
GKV-
S itzenverbandthe regional Statutory
Health Insurance
Physicians associations
Head Organisation
Statutory Health
Insurance
GKV-Spitzenverband: www.gkv-sv.de, in English: www.gkv-spitzenverband.de/Statutory_health_insurance.gkvnet
KBV: www.kbv.de
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Self Government on Federal Level
The Principles and Issues of Self Government in Outpatient Care
GKV SVHead Organisation
KBVNational Association
negotiate nationwide
a u ory ea
Insurance
a u ory ea
Insurance
Physicians
ramewor
Basic Contract Doctor-SHI and payment
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Self Government on Federal Level
-
Federal Joint Commitee
Picture by G-BA
authorised by law to issue legally binding directives
represents providers, SHI funds and patients
uses extern and impartial assesment (IQWiG)
main decision criteria are: evidence, costs/benefits and harm
Picture by Gemeinsamer Bundesausschuss: www.g-ba.de, in English: www.g-ba.de/institution/sys/english/
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Self Government on Federal Level
- " "
13 Voting Members: 5 Non Voting Members:
3 Impartial Members
Members
Patient-
Members
Provider
Members
SHI
(2 KBV)
(1 KZBV)
-
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Self Government on federal level,
Negotiating basic components of the relationship doctors - SHI
GKV SVHead Organisation
KBV
National Association
negotiate nationwide
a u ory ea
Insurance
a u ory ea
Insurance
Physicians
ramewor
Basic Contract Doctor-SHI and payment
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Self Government on Federal Level,
-
-
"Arzt-/Ersatzkassenvertrag (EKV)"autorisation for treatment
forms (e.g. prescriptions) and documentation
opening duration of doctor's practice, visits at patients homecollecting practice fees
sanctions
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Self Government on Federal Level,
Committee for Ratin Doctors Services
6 Voting Members:additional 3 Voting Impartial Members*
Members
KBV
Members
SHI
- an
reach no agreement
-
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Self Government on Federal Level,
Committee for Ratin Doctors Services
"Bewertungsausschuss"Uniform
Fee
classifies the price for each doctors service* [in points]
defines each single outpatient service*("einheitlicherBewertungs-
"
defines broad renumeration
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Self Government on Federal Level
Fee Schedule Item Service Definition of ServiceHere: tress-E
Special Accounting Rules
Number of Points
if point-value is 3,5048 Ct,Here: an additional ECG (13 250) is not allowed oc or s paymen s ,
(incl. office-rent, material,wages,...)
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Self Government on Federal Level
The Uniform Fee Shedule with Accountin Directives for ...
all Physicians General Practit ioners
+
Specialists
+,
records
care at
supplementary fees
Basic rates are graded to
special services
Basic rates are
night/weekend
emergency
the age
supplementary fee:
graded to the age
different fee items for
visit at patients
home
selected special services:
longtime ECG, spirometry...screening and early
detection
Note: accounting period is allways the quarter of the year
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Agenda
2 Self Government on Federal Level Principles of Self Government
Pla ers
Catalogue of Benefits
u , y
3 Self Government on State Level Players
Re ional Rules of Renumeration
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Self Government on State Level
Regional Players -Negotiating the regional contracts
e
vel
Landesverbnde der
Krankenkassen
KV
Association of Statutory Health
State
Negotiating Organisations
of the Health Insurance
Funds (SHI) in State
nsurance ys c ans n a e
-
Additional Services
Supply of Pharmaceuticals
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Self Government on State Level
Vereinigung (KV)
Association of Statutory
Package(members
x
(EBM- Uniform FeeShedule)
ea nsurance ys c ans
in StateDoctor
Doctor Sin le SHI FundRules for the distribution ofv
el
Single SHI FundDoctor for example: extrabudgetary/budgetaryta
te
L
Single SHI Fundn erven ons General Practitioners/
Specialists
point value adjusting
Payment: point value x pointsum(single Physician)Doctor
standardised maximumDoctor
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Self Government on State Level
Previous: SHI funds pay a overall remuneration (capitation x SHI-Members) to
KVen, based on the needs and outpatient services in 1993
- -
The overall renumeration varies analogous with the wage growth(maximum) not with the changed needs for medical services
Consequence: Pa ments do not meet the real needs
No compatibility with the new financial terms (morbidity adjusted riskstructure compensation scheme, Gesundheitsfonds (health care stock))
Future: Payment will depend on patient's state of health
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Self Government on State Level
calculated
Vereinigung (KV)
Association of Statutory
(EBM- Uniform Fee
Shedule)
Individual needsof each insured
xea nsurance ys c ans
in StateDoctor
Doctor Sin le SHI FundRules for the distribution ofv
el
Single SHI FundDoctor for example: extrabudgetary/budgetaryta
te
L
Single SHI Fundn erven ons General Practitioners/
Specialists
point value adjusting
DoctorPayment: merits in
(single physician)up to individual standardised
Doctor
maximum (depending on
morbidity)
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Thank you for your attention!
www. -on ne. e